Maxam, Larry NEW YORK STATE DEPARTMENT OF HEALTA
Vital Records Section Burial - Transit Permit
,
- Name First Middle Last Sex
Larry R. Maxam Male
Date of Death Age If Veteran of U.S. Armed Forces,
August 29,2013 64 War or Dates Vietnam
t, Place of Death Hospital, Institution or
City, Town or Village Warrensburg Street Address 9 Hudson St.
Manner of Death X Natural Cause Accident I I Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
;0 Dr.Daniel Way MD
Address
�n ,TARN,Warrensburg,NY 12885
Death Certificate Filed District Number Register Number
-
City, Town or Village Warrensburg 5660
❑Burial Date Cemetery or Crematory
II Entombment August 30,2013 Pine View Crematory
Address .
i Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
9. and/or Address
H" Hold
N
0 Date Point of
O. 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
`'`'I Address
3809 Main Street,Warrensburg,NY 12885
-, Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is h reby granted to dispose of the human - ••,s descri d above as indicated.
Date Issued c3/-3 Registrar of Vital Stati i , C._,_,A.
(signature)
District Number 5660 Place Warrensburg
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of DispositionJ{?"/ Place of Disposition 4/v1/1/, j,e..' a4,1,dare,
E (address)
w
cn
re (section) t number) (grave number)
p Name of Sexton or ers n i rge of Premises c �(j � pr,,
Z (please print)
W Signature 61
Title �evrI w� 45.47-
(over)
DOH-1555 (02/2004)