Bartholomew, Gordon D r •
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NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records - ., ._
Name First Middle Last Sex
Gordon D.Bartholomew Male
Date of Death Age If Veteran of U.S.Armed Forces,
09/28/2021 58 Years War or Dates
i— Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address Belle Avenue,Queensbury Town,New York 12804
pManner of Death 0 Natural Cause XI Accident El Homicide ❑Suicide El Undetermined ❑Pending
Circumstances Investigation
OMedical Certifier Name Title
Timothy Murphy Coroner
Address
52 Haviland Avenue,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 203
ElBurial Date Cemetery,Crematory or Facility Name
09/30/2021 Pine View Crematory
❑Entombment Address
lCremation Queensbury Town,New York
❑Donation
Z Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
O. Date Point of
U) Li Transportation
p by Common Shipment
Carrier Destination
ElDisinterment Date Cemetery Address
IDReinterment 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
F- Remains are Shipped,If Other than Above
5 Address
CC
W
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/30/2021 Registrar of Vital Statistics Caroline.yfi&fegarde Barber(E(ectronicaCCy 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: /
Z Date of Disposition (O hi I Zl Place of Disposition go c(L l..4 o_
W
2 (address)
W
Q (section) ,/ (lot number) (grave number)
8 Name of Sexton or Person in Charge of Pr mises I h pint/5f. b-
W (pIL
tips++
Signature el G�.. Title WIC
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
01519 4
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
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Official Funeral Directors Reg.or License# '