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Cleveland, John NEW YORK STATE DEPARTMENT OF HEALTH U Vital Records Section Burial - Transit Permit Name First Middle Last Sex John R. Cleveland Male Date of Death Age If Veteran of U.S. Armed Forces, June 11,2015 81 War or Dates t,, Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital p; Manner of Death X Natural Cause Accident I I Homicide Suicide Undetermined Pending UI Circumstances Investigation tu Medical Certifier Name Title Dr.John Sawyer,MD Address 14 Manor Drive,Queensbury,NY 12804 Death Certificate Filed District Number Register Number City, Town or Village 5 6 ©, 3 0 0 ❑Burial Date Cemetery or Crematory ❑Entombment June 12,2015 Pine View Crematory Address ❑x Cremation Quaker Rd., Queensbury, NY 12804 Date Place Removed Z Removal and/or Held and/or Address H Hold CO O Date Point of N Transportation Shipment p by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Alexander-Baker Funeral Home 00035 Address 3809 Main Street,Warrensburg,NY 12885 Name of Funeral Firm Making Disposition or to Whom *; Remains are Shipped, If Other than Above 2 Address 4C Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 6 f'l 2 j (5 Registrar of Vital Statistics Us-) k � (signature) District Number 560) Place 6 Cs1,v -s ca l s t �) I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: tu• Date of Disposition (,fIsjir Place of Disposition ,� (address) re N (section) A (let number (grave number) rp Name of Sexton or Person in Charge of Premises W (please pnnt) Signature Title ttEkn (over) DOH-1555 (02/2004)