Long, George NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
George Long Male
Date of Death Age If Veteran of U.S. Armed Forces,
03/06/2013 84 years War or Dates
#-= P ce of Death Hospital, Institution or
i , To I Street Address
•
C cX Glens Falls park st a ens falls, n y 12801
anner of Death �:yatural Cause Accident 0 Homicide ElSuicide Undetermined ❑Pending
W.. Circumstances Investigation
at Medical Certifier Name Title
la
Frances C RollingPr M n
Address
100 Broad Street Glens Falls, NY 12801 ,
D Certificate Filed District Number Register Number
Ci Tow�x9f�✓i
axx Glens Fells 5601O
95
urial Date Cemetery or Crematory
;['Entombment Pine View Cemetery
Address
`TgCjemation Oueensbury, NY 12804
Date Place Removed
Z❑Removal and/or Held
and/or Address
k Hold
U)
0 Date Point of
iTransportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
vliiligi Permit Issued to Registration Number
Name of Funeral Home Maynard D. Baker Funeral Home 01130
Address
11 Lafayette Street Queensbury, N Y 12804
iiiiii Name of Funeral Firm Making Disposition or to Whom
14. Remains are Shipped, If Other than Above
2 Address
a
at
'` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/07/2013 Registrar of Vital Statistics ;]J C& . v.¢
(signature)
District Number Place //J I ate/
5601 Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 31- Place of Disposition --(21,t0un.l Cowforio..
2 (address)
LU
t/
CC (section) t,,4?pL_
(lot number) (grave number)
Name of Sexton or Person in Charge o Premises SeMgt
z ` (p/ekse print)
Signature l9— Title CC?"''(�I,
(over)
DOH-1555 (02/2004)