Woodruff, Dane Nicholas °6
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NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Dane Nicholas Woodruff Male
Date of Death Age If Veteran of U.S.Armed Forces,
08/27/2021 34 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Saranac Lake Village Franklin Street Address 16 Mills Avenue APT 3A,Saranac Lake Village Franklin,New York 12983
LU
W Manner of Death Natural Cause 0 Accident 0 Homicide 0 Suicide Undetermined El Pending
Circumstances Investigation
W Medical Certifier Name Title
G Ronald Keough Coroner
Address
40 Academy Street,Saranac Lake Village Franklin,New York 12983
Death Certificate Filed District Number Register Number
City,Town or Village Saranac Lake Village Franklin 1623 5
EIBurial Date Cemetery,Crematory or Facility Name
09/03/2021 Pine View Crematory
0 Entombment Address
ElCremation Queensbury Town,New York
0 Donation
O ❑Removal Date Place Removed
and/or and/or Held
p
Hold Address
0
Q- Date Point of
U) ❑Transportation
a by Common Shipment
Carrier Destination
0 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
p— Remains are Shipped,If Other than Above
,!E Address
CC
W
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/03/2021 Registrar of Vital Statistics Kamen"Iva y/r(Ekctronica/l'Srgned)
(signature)
District Number 1623 Place Saranac Lake Village Franklin, 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 9 7-2U'Z/ Place of Disposition / i)7,r2 vt'e4,t,I v
(address)
W
N (section) \ (lot number) (grave number)
Name of Sexton or Per on in C arge of Premises p eaeaseprint/
Z
Signature Title , �' ��� ��
DOH-1555(07/ p 1 of 2
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Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on 20
Pine View Cemetery Representing the funeral home lamed on burial permit
Official Funeral Directors Reg.or License#