Graham Jr., George Henry NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vitat Records
Name First Middle Last Sex
George Henry Graham Jr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
08/24/2021 80 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Argyle Town Street Address Washington Center For Rehabilitation And Healthcare
W
'p Manner of Death ❑X Natural Cause El Accident Ei Homicide ❑Suicide El Undetermined El Pending
Circumstances Investigation
W Medical Certifier Name Title
Leonard Gelman MD
Address
4573 State Route 40,Argyle Town,New York 12809
Death Certificate Filed District Number Register Number
City,Town or Village Argyle 5750 56
❑Burial Date Cemetery,Crematory or Facility Name
08/27/2021 Pine View Crematory
ElEntombment Address
X❑Cremation Queensbury Town,New York
❑Donation
ElRemoval Date Place Removed
and/or and/or Held
N Hold Address
0
a. Date Point of
coLi Transportation
G by Common Shipment
Carrier Destination
El 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
E— Remains are Shipped,If Other than Above
a Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/27/2021 Registrar of Vital Statistics Saielley31ckemon(EYectronicaffySigned)
(signature)
District Number 5750 Place Argyle, New York
I certify that the remains of
the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition Y/-2" zi Place of Disposition ?f)v J r C 1C-wu�(�'�/
2 (� (addreE)
W
(section) k (lot number) (grave number)
S Name of Sexton or Person' har of Pr mises O t 41 ,�5 4m .4
(please print)
tU Signature Title fe r✓t a 1-d^� e )/.at/I
DOH-1555(07/18)p 1 of
t. t;19
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on = , 20
;° •
Pine View€meter§ Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# s '1