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Waters, James Dean gill NEW YORK STATE DEPARTMENT OF H EALTH r-. Bureau of Vital Records — Burial - Transit Permit Name First Middle Last Sex James Dean Waters Male Date of Death ' Age If Veteran of U.S.Armed Forces, 11/22/2021 45 Years War or Dates H Place of Death Hospital,Institution or Z City,Town or Village Kingsbury Town Street Address 106 Queens Drive Apt A,Kingsbury Town,New York 12839 pManner of Death ©Natural Cause 0 Accident 0 Homicide EI Suicide Undetermined 0 Pending U Circumstances Investigation WD Medical Certifier Name Title John Aiken Coroner Address 40 Burquist Road,Fort Ann Town,New York 12827 Death Certificate Filed District Number Register Number City,Town or Village Kingsbury Town 5762 21 Burial Date Cemetery,Crematory or Facility Name 11/24/2021 Pine View Crematory Ej Entombment Address • El Cremation Queensbury Town,New York ElDonation Z El Removal Date Place Removed and/or and/or Held . H Hold Address 0 CL Date Point of • ❑N Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address ElReinterment 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 1... Remains are Shipped,If Other than Above 5 Address W a' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/24/2021 Registrar of Vital Statistics Cynthia (Bardin(ECectronicaltySigned) (signature) District Number 5762 Place Kingsbury Town, 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 4/7.41I1 Place of Disposition � �,`, 2 /adre W U) CC (section) (grave number) g Name of Sexton or Person in Charge of Premises `l (lot.pumber) r.i �` . A"At(fi Z (p/eae print) IJJ Signature �� Title 1-P>C w►WTnE_ DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#