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Butler, Cody P. Ir5 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Cody P.Butler Male f Date of Death Age If Veteran of U.S.Armed Forces, efii 01/14/2021 28 Years War or Dates F- Place of Death "Hospital,Institution or City,Town or Village , Warrensburg Town Street Address 1078 Schroon River Road,Warrensburg Town,New York 12885 al p Manner of Death 0 Natural Cause 0 Accident 0 Homicide 0 Suicide 0 Undetermined ©Pending ILI Circumstances Investigation W Medical Certifier Name Title Ci Connie Goedert Coroner : Address 1400 St Route 9,Lake George Town,New York 12845 ,,c, Death Certificate Filed District Number Register Number ' City,Town or Village Warrensburg 5660 1 ' :r Burial Date Cemetery,Crematory or Facility Name 01/25/2021 Pine View Crematory ❑Entombment Address ^r ❑Cremation Queensbury Town,New York ❑Donation 'r; X ❑Removal Date Place Removed and/or and/or Held N Hold Address '$ J II a Date Point of (l)❑Transportation Gl by Common Shipment a, Carrier Destination t ," El Disinterment Date Cemetery Address _ Reinterment Date Cemetery Address ,. Permit Issued to Registration Number Name of Funeral Home Alexander Baker Funeral Home 00037 Address _, 3809 Main St,Warrensburg,New York 12885 Name of Funeral Firm Making Disposition or to Whom F' Remains are Shipped,If Other than Above 2 Address C W �': Permission is hereby granted to dispose of the human remains described above as indicated. <-,. Date Issued 01/19/2021 Registrar of Vital Statistics Pame&a M Lloyd YE&ctronicalry Signed) (signature) District Number 5660 Place Warrensburg, New York A. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition I/li3►Zl Place of Disposition r�ILZfoty.,_ W ,2 (address) W re N, (section) ! (tot numberJ (grave number) ci Name of Sexton or Person in Charge of Premise �t.1 ,)0v0414 z (plea e ,- print) LLI SignatureZ Title f Z i� — DOH-1555(07/i8)p 1 of 2 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#