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Cleveland, Paul V. 1P),, pg NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Paul V.Cleveland Male Date of Death Age If Veteran of U.S.Armed Forces, 08/05/2021 80 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Ticonderoga Town Street Address Heritage Commons Residential Health Care p Manner of Death © Natural Cause Accident Homicide 0 Suicide ❑Undetermined 0 Pending Circumstances Investigation W Medical Certifier Name Title G Nicholas Montello NP Address 1019 Wicker St,Ticonderoga Town,New York 12883 Death Certificate Filed District Number Register Number City,Town or Village Ticonderoga 1564 41 ❑Burial Date Cemetery,Crematory or Facility Name 08/10/2021 Pine View Crematory ❑Entombment Address X❑Cremation Queensbury Town,New York Donation Removal Date Place Removed and/or and/or Held NF- Hold Address 0 a. Date Point of U) ❑Transportation Q by Common Shipment Carrier Destination 0 Disinterment Date Cemetery Address Reinterment 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 11J O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 08/09/2021 Registrar of Vital Statistics 7onya 7Y1Thompson(ECectronica1(y Signed) (signature) District Number 1564 Place Ticonderoga, 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 lit 17.( Place of Disposition -n4LIJU 2 (address) W CC N (section) (/ot number) (grave number) Name of Sexton or Person in Charge of emises RhA.��t (p se print) ;��/f W Signature J Title N(�C DOH-1555(07/18)p 1 of 2 OI O25 Public Health Law Sec. 4145(2b) Receipt • Human remains of delivered on I , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg. or License# .�'