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Anselmo Sr., James Jacob tr Cc) NEWYORKSTATEDEPARTMENTOFHEALTH BureauBurial - Transit Permit of Vital Records Name First Middle Last Sex James Jacob Anselmo Sr. Male Date of Death Age If Veteran of U.S.Armed Forces, 07/06/2021 77 Years War or Dates Place of Death Hospital,Institution or W City,Town or Village Johnsburg Town Street Address 4235 State Route 28,Johnsburg Town, New York 12853 • Manner of Death © Natural Cause ❑Accident Homicide El Suicide 11 Undetermined ❑Pending Circumstances Investigation W Medical Certifier Name Title a John Lukaszewicz MD Address 101 Ridge Street 2,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village North Creek 5655 21 El Burial Date Cemetery,Crematory or Facility Name 07/08/2021 Pine View Crematory ❑Entombment Address lCremation Queensbury Town,New York ElDonation o• ElRemoval Date Place Removed and/or and/or Held H Hold Address 0 O. Date Point of N ❑Transportation Shipment p by Common Carrier Destination Disinterment Date Cemetery Address EReinterment 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 1— Remains are Shipped,If Other than Above 2 Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 07/08/2021 Registrar of Vital Statistics 1(p.th(een C.Gorah(E(ectronicalty Signed) (signature) District Number 5655 Place North Creek, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Zp 1Disposition W Date of Disposition 7 a � Place of (address) W CC CC (section) (lot number) (grave number) SName of Sexton or Person in Charge of Pre ' es `:-�' (plea print) CPC/ACVW Signature Title DOH-1555(07/18)pi of 2 Public Health Law Sec. 4145(2b) 14 9 2 5 Receipt Human remains of delivered on , 20 J . Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#