Spencer, Wayne Wilbur NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Wayne Wilbur Spencer Male
Date of Death Age If Veteran of U.S.Armed Forces,
07/17/2021 63 Years War or Dates
ZPlace of Death Hospital,Institution or
City,Town or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing
p Manner of Death g Natural Cause El Accident ❑Homicide E=I Suicide Undetermined Pending
VCircumstances Investigation
WG Medical Certifier Name Title
Roslyn Socolof MD
Address
42 Gurney Ln,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 152
CIBurial Date Cemetery,Crematory or Facility Name
07/23/2021 Pine View Crematory
12 Entombment Address
Cremation Queensbury Town,New York
Donation
0 El
Removal Date Place Removed
and/or and/or Held
Hold Address
N
O
a. Date Point of
tt)❑Transportation
p by Common Shipment
Carrier Destination
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
Remains are Shipped,If Other than Above
2 Address
it
W
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/22/2021 Registrar of Vital Statistics Carolinexl1gard'Bader(El ctronicat Signer)°
(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:
II—
WDate of Disposition )—�- t Place of Disposition Q;ot,, V; Grer►c/cry
(address)
W
N
CC (section) (lot number) (grave number)
SName of Sexton or Person in Charge of Premises J e Crwv'
Z (please print)
W Signature - Title
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) y -• 3141 9 77
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#