Fenton, Paul Joseph * IIIC
NEW YORK STATE DEPARTMENT OF HEALTH u 4 - Burial - Transit Permit
Bureau of Vital Records
Name First Middle ` Last Sex
Paul Joseph Fenton Male
Date of Death Age If Veteran of U.S.Armed Forces,
11/08/2020 73 Years War or Dates
F. Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address 10 Douglas Avenue,Glens Falls,New York 12801
LLI
p Manner of Death 0 Natural Cause El Accident Ei Homicide 0 Suicide Undetermined Pending
WLi
U Circumstances Investigation
WC1 Medical Certifier Name Title
Joseph Mihindukulasuriya MD
Address
20 Murray Street,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 505
ElBurial Date Cemetery,Crematory or Facility Name
11/11/2020 Pine View Crematory
El Entombment Address
ElCremation Queensbury Town,New York
Donation
ZRemoval Date Place Removed
and/or and/or Held
f- Hold Address
N
0
d Date Point of
VI ❑Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
ElReinterment 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
2 Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/10/2020 Registrar of Vital Statistics kP6ert)1ndretu Cultic(Ekctronica835igned)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
Z Date of Disposition 11/12 1 is Place of Disposition RILL ACV'
W
2 (address)
W
(I)
CC (section) /ot number) (grave number)
0 Name of Sexton or Person in Charge of Prem. e (�a 1�(pleaserint/
W
Signature G�../' t Title !
DOH-1555(o7/18)p 1 of 2
1 0141 7
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# ; r