Sheets, John Charles POrZ
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
John Charles Sheets Male
Date of Death Age If Veteran of U.S.Armed Forces,
08/01/2021 80 Years War or Dates 1961 -1965
F Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death IJ Natural Cause 1=1 Accident Homicide ❑Suicide 0 Undetermined 0 Pending
W Circumstances Investigation
U
W Medical Certifier Name Title
CI Marcille Labban MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 320
Burial Date Cemetery,Crematory or Facility Name
08/06/2021 Pine View Crematory
❑Entombment Address
gCremation Queensbury Town,New York
El Donation
6 CI Removal Date Place Removed
and/or and/or Held
H Hold Address
0
a Date Point of
t/) L Transportation Shipment
p by Common
Carrier Destination
Date Cemetery Address
ElDisinterment
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
1— Remains are Shipped,If Other than Above
Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/03/2021 Registrar of Vital Statistics Rpgert.Ararrew Curtis(EkctrvnicalyStgned)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition g'/OI Z( Place of Disposition tnt�
(address)
W
CC N (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Prem.
Z (phase print)
tL Signature Title
DOH-1555(o7/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt l
IHuman remains of ---'4 * "`-' -. delivered on 20 -
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# 6 ! ( - 6;1