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Osterhout, Henry I NEW YORK STATE DEPARTMENT OF HEALTH Burlap - Transit Permit Bureau of Vital Records Name First Middle Last Sex Henry I.Osterhout Male Date of Death Age If Veteran of U.S.Armed Forces, 09/06/2021 78 Years War or Dates Place of Death Hospital,Institution or W City,Town or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing p Manner of Death © Natural Cause ❑Accident ❑Homicide ElSuicide ❑Undetermined ❑Pending Circumstances Investigation W Medical Certifier Name Title O Jennifer Donovan DO Address 42 Gurney Ln,Queensbury Town, New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 186 ❑Burial Date Cemetery,Crematory or Facility Name 09/09/2021 Pine View Crematory ❑Entombment Address X❑Cremation Queensbury Town,New York ❑Donation O ❑Removal Date Place Removed and/or and/or Held - Hold Address O a Date Point of in ❑Transportation Q by Common Shipment Carrier Destination ❑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 — Remains are Shipped,If Other than Above Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 09/08/2021 Registrar of Vital Statistics Caroline Jfi(fegarie rdar6er(ECectronica1Ty Signed) (signature) District Number 5657 Place Queensbury, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition Q III I i.- Place of Disposition 7c 2 (ad cress) W CC (section) (lot number) (grave number) 8 Name of Sexton or Person in Charge of Premiss n 1l-' .500.4 T ( ease print) / W 41.Signature L� Title 4 � DOH-1555(07/18)p 1 of 2 1 w Public Health Law Sec. 4145(2b) n 1 512 2 1 Receipt 1 t � Human remains of P `'' - , delivered on i' ,� , 20 " / r Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# ' !''�" c/