DeCesare, Gary Neil . . 3,11
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital.Records
Name First Middle Last Sex
Gary Neil DeCesare Male
Date of Death Age If Veteran of U.S.Armed Forces,
05/02/2021 65 Years War or Dates
i.. Place of Death Hospital,Institution or
WCity,Town or Village Lake Luzeme Town Street Address 65 Old Stage Road,Lake Luzerne Town,New York 12846
p Manner of Death a Natural Cause El Accident I=1 Homicide ❑Suicide Undetermined Pending
W Circumstances Investigation
WMedical Certifier Name Title
G Joseph Mihindukulasuriya MD
Address
20 Murray Street,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Lake Luzeme 5656 6
Burial Date Cemetery,Crematory or Facility Name
05/06/2021 Pine View Crematory
Entombment Address
ElCremation Queensbury Town,New York
Donation
60 Removal Date Place Removed
and/or and/or Held
H N Hold Address
0
n. Date Point of
Cl) Li Transportation Shipment
Q by Common
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
F. Remains are Shipped,If Other than Above
Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/06/2021 Registrar of Vital Statistics Cynthia Slerruood('kctronical6iSgnea
(signature)
District Number 5656 Place Lake Luzerne, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H
Z Date of Disposition Sew 1.7( Place of Disposition ��--
2 1 address)
W
CC (section) Allot number) (grave number)
IrsIV�� �H
Name of Sexton or Person in Charge of Premise; �"`
/ (pleas print)
W oo
Signature Title wJ� �
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 01 4 7 6 2
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# ;