Katz, Alexander Jack tr
NEW YORK STATE DEPARTMENT OF HEALTH4116 Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Alexander Jack Katz Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/17/2021 79 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address 72 Surrey Fields Drive,Queensbury Town,New York 12804
t Manner of Death ❑. Natural Cause El Accident El Homicide 1=1 Suicidejr—IUndetermined ❑Pending
WI
Circumstances Investigation
W Medical Certifier Name Title
CI Paul Bachman MD
Address
9 Carey Rd,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 20
❑Burial Date Cemetery,Crematory or Facility Name
01/20/2021 Pine View Crematory
❑Entombment Address
0 Cremation Queensbury Town,New York :":
ElDonation
0 Removal Date Place Removed
1:1and/or and/or Held
H N Hold Address
0
EL Date Point of
(!) Li Transportation
p by 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
H Remains are Shipped,If Other than Above
N Address
CC
LJ
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/20/2021 Registrar of Vital Statistics CarnCinexklegard Bader(E/ctronicalr Signed)
(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:
Z L �
Date of Disposition "rill 1 Place of Disposition
2 (address)
W
CC N (section) 50numberli / (grave number)
0 Name of Sexton or Person in Charge of P miles — it)
(please pr t/
W Signature Title C �tt1v'�
DOH-1555(o7/18)p i of 2
Public Health Law Sec. 4145(2b) 0 1 4 4 J 9
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#