Squier Sr., Barry James N. V ) o3
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Barry James Squier Sr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/10/2020 84 Years War or Dates
f— Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address Glens Falls Hospital
O Manner of Death Natural Cause 1=1Accident ❑Homicide I:ISuicide Undetermined Pending
Circumstances Investigation
W• Medical Certifier Name Title
CI Asim Chaudry MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 567
❑Burial Date Cemetery,Crematory or Facility Name
12/14/2020 Pine View Crematory
ElEntombment Address
f]Cremation Queensbury Town,New York
ElDonation
m
6 El Removal Date Place Removed
and/or and/or Held
F- Hold Address
th
0
G. 1-1 Date Point of
N ❑Transportation
CI Common Shipment
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
F Remains are Shipped,If Other than Above
% Address
Cr
W
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/14/2020 Registrar of Vital Statistics Rptert}nu7rew Curtis gkctranica(Signed)
(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 •
F- 74--
W Date of Disposition FZ'IS iTO Place of Disposition Lk
2 (ddress)
W
NCC (section) /f (lot nun (grave number)
Name of Sexton or Person in Cha of Premises rY z /p/ase print)
W Signature Title `1iri ��
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) • • • - 1.42 q
Receipt
Human remains of - delivered on , 2Q
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# - ,