Boduch Sr., Joseph Michael NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Joseph Michael Boduch Sr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
09/10/2021 69 Years War or-Bates
Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address 41 Queen Mary Drive,Queensbury Town,New York 12804
p Manner of Death Q Natural Cause Accident Homicide ❑Suicide Undetermined Pending
C.) Circumstances Investigation
W Medical Certifier Name Title
Connie Goedert Coroner
Address
1400 St Route 9,Lake George Town,New York 12845
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 191
Burial Date Cemetery,Crematory or Facility Name
09/13/2021 Pine View Crematory
❑Entombment Address
Cremation Queensbury Town,New York
❑Donation
01=1 Removal Date Place Removed
and/or and/or Held
N Hold Address
0
a Date Point of
co Li Transportation
by Common Shipment
Carrier Destination
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
Remains are Shipped,If Other than Above
Address
Lu
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/13/2021 Registrar of Vital Statistics Carnlinelafegari Ban5er(Ekctronical5'49ned)
(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:
Date of Disposition rJ! l /) I Place of Disposition P jPe, Y I t.1) COCi"eikr
2 (address)
W
(section) (lot number) (grave number)
GName of Sexton or Person in Charge of Premises .kc m lL 5
please print)
W Signature /417>uril Title rC,rti?c1.°�
DOH-1555(07/18)p 1 of 2
I0..,t F;.1. II 0
Public Health Law Sec. 4145(2b)'` '
Receipt
•Human remains of ' 1,-' ' "• '`��- '''• -_:a delivered on • , 20 '
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# `