Porter, Jay •ill 4.1 # i i
NEW YORK STATE DEPARTMENT OF HEALTH 4
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Jay Gilmore Porter Male
Date of Death Age If Veteran of U.S. Armed Forces,
09/25/2013 71 years War or Dates
.. Place of Death Hospital, Institution or
City, Tow �Cj(i11 4(XX Glens Falls Street Address Glens Falls Hospital
Manner of Death Undetermined 0 Pending tural Cause Accident Homicide Suicide
Ili Circumstances Investigation
W Medical Certifier Name Title
C Shahid Ahmed Physician
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
>s City, TownXj(iIMIXXX Glens Falls 5601 405
ElBurial Date Cemetery or Crematory
Entombment 09/30/2013 Pine View Cemetery
Address
12114emation ( ueensbury, NY 12804
Date Place Removed
Z ni Removal and/or Held
). and/or Address
I= Hold
tI)
0 Date Point of
tL Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address •
Eli,iQ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D. Baker Funeral Home 01130
Address
11 Lafayette Street Queensburlr, N Y 12804
ik Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
CC
i
LL
Permission is hereby granted to dispose of the human r mains des ribed ab ye as indicat=d.
Date Issued "%a/26 ',013 Registrar of Vital Statistics • .- A.
(signature)
District Number Place
5601 Glens Falls
I certify that the remains of the decedent identified above wer disposed of in accordance with this permit on:
2
tti Date of Disposition IOlil 113 Place of Disposition u.,► C f .
(address)
LEt
CO
CC (section) A(lot number)t *'.� (grave number)
Name of Sexton or Person in Charge o remises ,,tt� , ,
2 (ple se print)
Signature Title mg.
r
(over)
DOH-1555 (02/2004)