Bender, Fields A �4t2
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Fields A.Bender Male
Date of Death Age If Veteran of U.S.Armed Forces,
09/09/2021 74 Years War or Dates 1969-1982
E., Place of Death Hospital,Institution or
W City,Town or Village Johnsburg Town Street Address Elderwood at North Creek
`p Manner of Death Natural Cause ❑Accident ElHomicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
W Medical Certifier Name Title
Kate Sauer-Jones PA
Address
112 Ski Bowl Rd,Johnsburg Town,New York 12853
Death Certificate Filed District Number Register Number
City,Town or Village North Creek 5655 35
❑Burial Date Cemetery,Crematory or Facility Name
09/13/2021 Pine View Crematory
❑Entombment Address
lCremation Queensbury Town,New York
❑Donation
o ElRemoval Date Place Removed
- and/or and/or Held
H Hold Address
N
0
O. Date Point of
U) ❑Transportation
ES Common Shipment
Carrier Destination
Disinterment
Date Cemetery Addy
Reinterment
Date Cemetery Ad ._ss
- 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
a Address
Q
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/10/2021 Registrar of Vital Statistics Kathleen C.Lorah(ECectronica1Ty Signed)
(signature)
District Number 5655 Place North Creek, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition —1 �
�ZpLf Place of Disposition ; jf refit 440
2 (address)
W
N CC (section) (tot number) (grave number)
SName of Sexton or Person in Charge of Premise I 7 m OrJ ci
nn (please print)
UJ a GL I V
W Signature �� � Title
DOH-1555(07/18)p 1 of 2
r
Public Health Law Sec. 4145(2b)
015136
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg. or License# •