Cook Jr, Gary NEW YORK STATE DEPARTMENT OF HEALTH R 4 tit
•
Vital Records Section
' Burial - Transit Permit
Name First Middle Last Sex
Gary F. Cook Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
08/22/2013 55 years War or Dates
Place of Death Hospital, Institution or
W �1 City, TX XXrXlaiNC Saratoga Springs Street Address 26D Allen Drive, Saratoga Springs, N Y
12 Manner of Death❑� Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
ILI Circumstances Investigation
W Medical Certifier Name Title
P. Alta
A. Gates PA
A Heat i Ctr., Broad Street
Death Certificate Filed District Number Register Number
City, TW4rXIMIRC Saratoga Springs 4501 347
❑Burial Date Cemetery or Crematory
08/22/2013 Pine View Crematory
❑Entombment Address
Cremation Queensbury N Y
Date Place Removed
Z Removal and/or Held
9❑and/or Address�
CA
Hold
O Date Point of
i❑Transportation Shipment
!J�
L by Common Destination
Carrier
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D. Baker Funeral Home 01130
Address
11 Lafayette Street, Queensbury, N Y
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
IX
III
f,7 Permission is hereby granted to dispose of the human rem . es jbed..app s indic ed.
Date Issued 08/22/2013 Registrar of Vital Statistics Q-�) ' r
(signature)
1.<' District Number 4501 Place Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI• Date of Disposition $1t3113 Place of Disposition ..agUiii.. tor`4"."
(address)
III
to
cc (section) (lot number) (grave number)
O Name of Sexton or Person in Charge f Premises t' ,) S�'�^�t+
(p/ ase print)
tLi
Signature Title azEmforTaL
(over)
DOH-1555 (02/2004)