Guyette, William NEW YORK STATE DEPARTMENJ OF HEALTH ` t' 0 S I
Vital Records Section �' Burial - Transit Permit
Name First Middle Last Sex
William Douglas Guyette Male
Date of Death Age If Veteran of U.S. Armed Forces,
War or Dates
#- Place/FOP 62 years Hospital, Institution or
Z City, To vNi .- Street Address •
141 X *•:• X Glens F 5 Uni StA t 3A
Manner o eath Natural Cause Accident ❑Homicide El Suicide t unaetermined ❑Pending
LU 0
Circumstances Investigation
ta Medical Certifier Name Title
0
Add es Toos rortrcse M D
100 Broadc St Glens Falls, Ny 12801
: Death Certificate Filed District Number Register Number
mii City, Towkibbe X Glens Falle 5601 193
['Burial a e Cemetery or Crematory
i>'> ['Entombment Address10/26/2012 Pine View Crematorium
❑Cfemation Queensbury, NY 12804
Date Place Removed
Removal and/or Held
and/or Address
F_► Hold
(t)
O Date Point of
a"Ei Transportation Shipment
G by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 I afayette Street Queensbury, N Y 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
#X
1U
97 Permission is hereby granted to dispose of the human remains described above as indicated.
Wi Date Issued 10/26/2012 Registrar of Vital Statistics l C& k -i..4 u)
(signatur
District Number Place
5601 Glens Falls, iv V f i
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
iii Date of Disposition to-2l-it „ O Place of Disposition t16.) C IOt"tO./
2 (address)
ILEA
W
CC (section) I (lot number) (grave number)
a Name of Sexton or Person in Charge Premises 40--414._ C 0
z (plefase print)
ki Signaturedil Title CR M14 i
(over)
DOH-1555 (02/2004)