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Hubert, Russell G &I S NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Russell G Hubert Male Date of Death Age If Veteran of U.S.Armed Forces, 08/12/2021 75 Years War or Dates 63-66 1— Place of Death Hospital,Institution or Z City,Town or Village Thurman Town Street Address 54 Combs Road,Thurman Town,New York 12885 W W Manner of Death Undetermined Pending ©Natural Cause 0 Accident Homicide ❑Suicide V Circumstances Investigation W Medical Certifier Name Title G Darci Gaiotti-Grubbs MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Athol 5659 009 ElBurial Date Cemetery,Crematory or Facility Name 08/16/2021 Pine View Crematory ElEntombment Address EiCremation Queensbury Town,New York ElDonation OZ ❑Removal Date Place Removed and/or and/or Held H N Hold Address 0 Date Point of L/) ❑Transportation Shipment p by Common Carrier Destination Date Cemetery Address ❑Disinterment Date Cemetery Address ElReinterment 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 I— Remains are Shipped,If Other than Above 5 Address Q W IL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 08/14/2021 Registrar of Vital Statistics Susan Staples(Electronically Signed) (signature/ District Number 5659 Place Athol, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I— W Date of Disposition gill/ I l( Place of Disposition (ad IA-- 4r 1.* •, dress) W U) (section) /(lot number) j�(grave number) CC cl Name of Sexton or Person in Charge of remises 1 (pleas print/ z lj ,tiir ie Ili Title DOH-1555(07/18)pi of 2 Public Health Law Sec. 4145(2b) 5 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# i.0