McInnis, James NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
''' Name First Middle Last Sex
James W. McInnis Male
Date of Death Age If Veteran of U.S. Armed Forces,
February 15,2014 73 War or Dates
4 ; ' Place of Death Hospital, Institution or
1 City, Town or Village Warrensburg Street Address 40 Oak Street
B.d Manner of Death n Natural Cause Accident ❑Homicide n Suicide Undetermined Pending
Circumstances Investigation
'tcti
Medical Certifier Name Title
1I Suzanne Bergin
Address
°-o y 3767 Main Street,Warrensburg,NY 12885
;, Death Certificate Filed District Number Register Number 5
City, Town or Village ThurmanWarrensburg 56595660
❑Burial Date Cemetery or Crematory
February 18,2014 Pine View Crematory
Entombment Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z 0 Removal and/or Held
and/or Address
t. Hold
N
0 Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
pi Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
: 3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
F Remains are Shipped, If Other than Above
:X Address
Permission is hereby granted to dispose of the human rema' s escribed abo as indic ted.
a Date Issued // I' Registrar of Vital Statistics C Gn
/ signature)
District Number 5660 Place Warrensburg
I certify that the remains of the decedent identified above were disposed of inIL
accordance with this permit on:
W Date of Disposition �/iiIp1 Place of Disposition -IL, C„cfofh,--
W (address)
U)
CL (section) J(lot umber) c (grave number)
QName of Sexton or Person in Charge of Premises /f/T., ✓ Jor4lt-
Z (pi se pant)
W
Signature 4L,
Title CIZEOATOIL
(over)
DOH-1555 (02/2004)