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Fifield, Jonathan W. cc NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records • Name First Middle Last Sex Jonathan W.Fifield Male Date of Death Age If Veteran of U.S.Armed Forces, 04/30/2021 49 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Warrensburg Town Street Address 20 Third Avenue,Warrensburg Town, New York 12885 Undetermined W Manner of Death © Natural Cause Accident Homicide ❑Suicide d Pending❑ ❑ Circumstances Investigation W Medical Certifier Name Title O Christopher Mason DO Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Warrensburg 5660 15 ❑Burial Date Cemetery,Crematory or Facility Name 05/04/2021 Pine View Crematory ❑Entombment Address X❑Cremation Queensbury Town,New York ❑Donation g ❑Removal Date Place Removed and/or and/or Held N Hold Address 0 O. Date Point of U) ❑Transportation p by Common Shipment Carrier Destination Date Cemetery Address D Disinterment ❑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 Address Q W Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/03/2021 Registrar of Vital Statistics rPame&a M GCoyd(ECectronicaCCy Signed) (signature) District Number 5660 Place Warrensburg, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition I H//I Place of Disposition uw- �,✓t+� 2 (address) W CC U) (section) (lojjumber) (grave number) Name of Sexton or Person in Charge of Premises t' �" S 44M Z L./ (please pri t) W Signature Title e12404441 a- DOH-t555(07/18)p t of 2 Public Health Law Sec. 4145(2b) f 0 1 4 7 5 E Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#