Sprague, Paul Lester it
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records —t
Name First Middle Last Sex
Paul Lester Sprague Male
Date of Death Age If Veteran of U.S.Armed Forces,
02/08/2021 76 Years War or Dates
F— Place of Death Hospital,Institution or
Z City,Town or Village South Glens Falls Village Street Address 18 Riverview Street APT#119,South Glens Falls Village,New York 12830
IU Manner of Death Undetermined Pending
W Natural Cause Accident Homicide Suicide
Circumstances Investigation
W Medical Certifier Name Title
G Glen Anderson PA
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village South Glens Falls Village 4524 5
❑Burial Date Cemetery,Crematory or Facility Name
02/09/2021 Pine View Crematory
EjEntombment Address
X❑Cremation Queensbury Town,New York
Donation
O• CIRemoval Date Place Removed
and/or and/or Held
H Hold Address
0
O. Date Point of
to 11 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
-. Remains are Shipped,If Other than Above
a Address
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/08/2021 Registrar of Vital Statistics Shannon 1CelTelrer(Electronical''SWned)
(signature)
District Number 4524 Place South Glens Falls Village, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 2/ti f 71 Place of Disposition L 4/7/tILI
otem
(address)
W
(section) (lot number) (grave number)
SName of Sexton or Person in Charge Premises I; n r.'rl�^ ��
(pleaJe print)
W Signature Title
DOH-1555(o7/t8)p i of 2
Public Health Law Sec. 4145(2b) .�
t 1„43 71)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#