Pain, Barry Don Ir'
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Barry Don Pain Male
Date of Death Age If Veteran of U.S.Armed Forces,
07/22/2021 84 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing
0 Manner of Death ❑, Natural Cause El Accident El Homicide 1=1 Suicide Undetermined ❑Pending
IJJ Circumstances Investigation
v
W Medical Certifier Name Title
0 Jennifer Donovan DO
Address
42 Gurney Ln,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 156
Burial Date Cemetery,Crematory or Facility Name
07/30/2021 Pine View Crematory
❑Entombment Address
0 Cremation Queensbury Town,New York
❑Donation
OZ El Removal Date Place Removed
and/or and/or Held
Hold Address
N
0
G. Date Point of
(/) ❑Transportation
Q by Common Shipment
Carrier Destination
Date Cemetery Address
ElDisinterment
ElReinterment 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
2 Address
CIC
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/30/2021 Registrar of Vital Statistics Carolinex(%gardl Bader(rEkctronicatySOne4
(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:
Il—
WDate of Disposition 2;3 n—d.O.zi Place of Disposition (.st A ./C/
2 (address)
W
CC N (section) (lot number) (grave number)
S
G Name of Sexton or Perso 'n Charge of Premises ��1h Qi/� S ,lf �f.
(please print)
W Signature Title re,M",loc
DOH-1555(0 p 1 of 2
Public Health Law Sec. 4145(2b) 01 4 9 91.
Receipt
•
Human remains of • delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# e=-