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Pierson, Donald Henry r II 31 ) NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Donald Henry Pierson Male Date of Death Age If Veteran of U.S.Armed Forces, 7n 05/04/2021 49 Years War or Dates t... Place of Death Hospital,Institution or Z. City,Town or Village Queensbury Town Street Address 16 Ryan Avenue,Queensbury Town, New York 12804 p Manner of Death ©Natural Cause 0 Accident Homicide Suicide Undetermined Pending Circumstances Investigation ILI Medical Certifier Name Title G Glen Anderson PA Address r; 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 103 ❑Burial Date Cemetery,Crematory or Facility Name 05/06/2021 Pine View Crematory . U Entombment Address ❑X Cremation Queensbury Town,New York '' ❑Donation 0 El Removal Date Place Removed and/or and/or Held F_- Hold Address N 0 d Date Point of (/) 1-1 Transportation Shipment p by Common Carrier Destination 1-1 Li Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address ii. 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 CC a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/05/2021 Registrar of Vital Statistics Caroline7{i(legarde Barber(ElectronicallySigned) (signature) District Number 5657 Place Queensbury, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: /� Date of Disposition TN 124 Place of Disposition `I ,+'4�li `i+w"fd f^t..,� 2 (address) W NLC (section) (lot number) (grave number) S' Name of Sexton or Person in Charge of remises C!' 6-- St4 40 z (—; � (p/e print) W S Title (k4rMi4 Signature DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 r Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#