Hughes Jr., William John It 1L1�
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
William John Hughes Jr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
11/15/2020 79 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address 196 Luzerne Road,Queensbury Town,New York 12804
p Manner of Death 0 Natural Cause Accident Ej Homicide 1=1 Suicide ❑Undetermined El Pending
W Circumstances Investigation
W Medical Certifier Name Title
Anne Evans DO
Address
3 Irongate Center,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 207
Burial Date Cemetery,Crematory or Facility Name
11/17/2020 Pine View Crematory
❑Entombment Address
ElCremation Queensbury Town,New York
❑Donation
Removal Date Place Removed
and/or and/or Held
H o Hold Address
0
a Date Point of
u Transportation Shipment
Q by Common
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
if Address
Q
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/17/2020 Registrar of Vital Statistics Carotinexliegara Bather(EkctronicalySigned)
(signature)
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
~ �..Ic
Z Date of Disposition I�'f��� Place of Disposition
Zt.'"
2 (a duress)
W
N (section) (lat number) (grave number)
0 Name of Sexton or Person in Charge emises
0 (pie se print)
Z li'1* I..
Signature W Signature Title
DOH-1555(o7/t8)p t of 2
Public Health Law Sec. 4145(2b) t�14 211
Receipt
Human remains of `" delivered on , , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#