Sheerer, Keith Brian -,:t71 7
NEW YORKSTATE DEPARTMENT OF HEALTH
Bureau of Vital Records
AirBurial - Transit Permit
Name First Middle Last Sex
Keith Brian Sheerer Male
Date of Death Age If Veteran of U.S.A ces,
03/16/2021 67 Years War or Dates
F— Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
W
O Manner of Death ❑a Natural Cause ❑Accident Ei Homicide Ej Suicide 0 Undetermined El Pending
UJ
U Circumstances Investigation
W Medical Certifier Name Title
O Jeremy Di Bari MD
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 145
EIBurial Date Cemetery,Crematory or Facility Name
03/19/2021 Pine View Crematory
0 Entombment Address
ElCremation Queensbury Town,New York
Ei Donation
ZZ• ElRemoval Date Place Removed
- and/or and/or Held
E- Hold Address
N
0
O. Date Point of
N Li Transportation
p by Common Shipment
Carrier Destination
Ei
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
5 Address
CC
1tt
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/17/2021 Registrar of Vital Statistics Ro6ert,?ndrewCurtis(Ekctronicaf 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 on:
I— Date of Disposition 31"u ii( Place of Disposition 1?jL
Zito__
W (address)
W
N (section) n� (lot number) (grave number)
o // IIL .S
G Name of Sexton or Person in Charge of Prem. es r`' ""�"
(plea a print)
W Signature z
a I— Title ��tCM�IjoY(
DOH-1555(07/18)pi of 2
1 V
Public Health Law Sec. 4145(2b) 1 4 r. fi
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on b
Official Funeral Directors Reg.or License#