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Baker, Rupert John
1111 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Rupert John Baker Male Date of Death Age If Veteran of U.S.Armed Forces, 10/29/2021 57 Years War or Dates 1981-1987 Place of Death Hospital,Institution or WCity,Town or Village Hudson Falls Village Street Address 7 Myrtle Avenue A, Hudson Falls Village,New York 12839 p Manner of Death ©Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined Pending W Circumstances Investigation U W Medical Certifier Name Title CI Rachel Grimm MD Address 113 Holland Ave,Albany,New York 12208 Death Certificate Filed District Number Register Number City,Town or Village Hudson Falls Village 5726 30 Burial Date Cemetery,Crematory or Facility Name 11/08/2021 Pine View Crematorium Entombment Address X❑Cremation Queensbury Town,New York Donation OZ Removal Date Place Removed and/or and/or Held N Hold Address 0 O. Date Point of CD ❑Transportation Shipment Q by Common Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above Address CC W C' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/01/2021 Registrar of Vital Statistics Cynthia ABartuin(ECectronicaliySigned) (signature) District Number 5726 Place Hudson Falls Village, 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 I Zf Place of Disposition 'FOCAL. > t. W (address) W CC N (section) � . (!otnumber) (grave number) 0 Name of Sexton or Person in Ch a of Premises n' ,Gd l 'J{ 4ease print/ (yn tU Signature C/' `,�� Title � ' Y I�- g DOH-1555(07/18)p 1 of 2 0_' t�,3( 9 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial.p9.rmit Official Funeral Directors Reg.or License#