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Baker, James E
;l .i joqz NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex James E.Baker Male Date of Death Age If Veteran of U.S.Armed Forces, 12/04/2021 68 Years War or Dates Army Place of Death Hospital,Institution or Z City,Town or Village Queensbury Town Street Address 105 4th Street,Queensbury Town,New York 12804 ILI p Manner of Death ©Natural Cause u Accident ❑Homicide ❑Suicide Undetermined ❑Pending W Circumstances Investigation EMedical Certifier Name Title �O Christopher Mason DO Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 232 ❑Burial Date Cemetery,Crematory or Facility Name 12/06/2021 Pine View Crematory ❑Entombment Address X❑Cremation Queensbury Town,New York ❑Donation Z❑Removal Date Place Removed and/or and/or Held F Hold Address CO 0 Cl)O. ❑Transportation Date Point of p by Common Shipment Carrier Destination ❑Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address 407 Bay Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom NRemains are Shipped,If Other than Above Address Jr If Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/06/2021 Registrar of Vital Statistics Caroline WfiCfegarde Barber(ECectronicallySigned) (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:t Date of Disposition /2- 7-US/ Place of Disposition Pa,4 V re- .) -fe.} 4,41 IIJ (address) W N Q (section) /lot number) (grave number) gName of Sexton or Perso an Ch r e of Pre ises Jk. k.v1 ( .-64A.di G Z (please print) W Signature Title Lre r"6-47 are/v�d DOH-1555(o7/18)p i of ✓ s ii ,4p. a 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#