Balch, Jan NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Jan Joseph Balch Male
Date of Death Age If Veteran of U.S. Armed Forces,
02/08/2013 58 years War or Dates
14 Place of Death Hospital, Institution or
CityLU , Tow /iX Glens Falls Street Address Glens Falls Hospital
Manner of Death❑yatural Cause ❑Accident ❑Homicide ❑Suicide El❑Undetermined ❑Pending
W. Circumstances Investigation
Lu Medical Certifier Name Title •
) Ageel A. Gillani Mi
Address
102 Park Street Glens Falls, N Y 12801
Death Certificate Filed District Number Register Number
City, Tow • i/iIXX C,lens Falls 5601 59
iiil❑Burial Date Cemetery or Crematory
❑Entombment 02/08/2013 Pine View Crematorium
Address
Iiii.i❑Cyemation Queensbury, NY 12804
Date . Place Removed
Z Removal and/or Held
❑and/or
i; Hold Address
tit)
O. Date Point of
01 Transportation Shipment
C by Common Destination
Carrier
El Disinterment Date Cemetery Address
ii•iiiiReinterment Date Cemetery Address
iliii LiPermit Issued to Registration Number
ni Name of Funeral Home Maynard D. Baker Funeral Home 01130
Miiii 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
CC
Permission is hereby granted to dispose of the human remains d scribed a ve icated.
inii Date Issued 02/11/2013 Registrar of Vital Statistics "7er/
(signature)
District Number 5601 Place Glens Falls
`;_::::: I certify that the remains of the decedent identified above were disposed of(fr�,� �*in'n accordance with this permit on:
• Date of Disposition 2�t.y-13 Place M of Disposition , ,U 1,0.....,
(address)
LU
CO
CC (section) Aoirfif—
(lot number)^^� (grave number)
i• Name of Sexton or Person in Charge of remises
2 (please print)
41LiaSignature Title CiLF,:MYtTOit
(over)
DOH-1555 (02/2004)