Marty, James NEW YORK STATE DEPARTMENT OF HEALTIV -NZ 9e
Vital Records Section '' Burial - Transit Permit
Name First Middle Last Sex
James Ellis Marty Male
Date of Death Age If Veteran of U.S. Armed Forces,
05/90/2n1l 78 years War or Dates 1952-1956
j-- Place of Death Hospital, Institution or
X City, Tow it Street Address
lL XX Glens Falls (�IPnc Falk Hncrital
Manner of Death❑Natural Cause ElAccident El Homicide Suicide Undetermined Pending
ItiCircumstances Investigation
ul Medical Certifier Name Title
gt. Joseph C Mihindu MD
Address
20 Murray Street, Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
ai City, Towr Aa.A" XX Glens Faik 5An1 221
i.lii ❑Burial Date Cemetery or Crematory
DEntombment 05/22/9013 Pine ViPw Cemetery
Address
DCsemation (Di,eenshury, NY 12804 .
Date Place Removed
Removal and/or Held
and/or Address
M= Hold
0
Date Point of
Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
.: D Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D. Baker Funeral Home 01130
iiiiiiiii Address
11 Lafayette Street Queensbury. N Y 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
C
Ili
• Permission is hereby granted to dispose of the human remains described ab sin ed.
ifli Ad
Date Issued 05/22/2013 Registrar of Vital Statistics -
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
la Date of Disposition Z - t3 Place of Disposition P( Iv V c '' Cdr.,rtA4-6" J(as)111
/
l
ir (section) ber) (grave number)
Name of Sexton Pe o J rge of Premises ,
At
�
2 �,�,,(p ease print)
Signature Title Oe `Ph t_
(over)
DOH-1555 (02/2004)