Arehart, Patrick J. 2WC)
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Patrick J.Arehart Male
Date of Death Age If Veteran of US.Armed Forces,
03/07/2021 50 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Malta Town Street Address 5 Summerwind Lane 5C, Malta Town, New York 12020
p Manner of Death Natural Cause El Accident El Homicide Suicide ❑Undetermined ❑Pending
Circumstances Investigation
W Medical Certifier Name Title
0 Susan Hayes-Masa Coroner
Address
6012 County Farm Road 1192,Ballston Spa Village;New York 12020
Death Certificate Filed District Number Register Number
City,Town or Village Malta 4560 17
❑Burial Date Cemetery,Crematory or Facility Name
03/10/2021 Pine View Crematory
❑Entombment Address
lCremation Queensbury Town,New York
Donation
g Removal Date Place Removed
and/or and/or Held
F-N Hold Address
0
Id. Date Point of
N LiTransportation
p by Common Shipment
Carrier Destination
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
Remains are Shipped,If Other than Above
2 Address
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/09/2021 Registrar of Vital Statistics Jennifer Marie 7ii 1 nes(ECectronically Signed)
(signature)
District Number 4560 Place Malta, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
~ G✓Imo_
Z Date of Disposition Nil 71 Place of Disposition
(address)
W
N
(section) (lot num r) (grave number)
SName of Sexton or Person in Charge of Prem' s iift.° 441
Z (please print)
W .Z.9
Signature Title
4-1555(07/18)p i of 2
014628
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#