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Backus, James Clarence
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex James Clarence Backus Male Date of Death Age If Veteran of U.S.Armed Forces, 12/23/2021 78 Years War or Dates 1965-1967 H Place of Death Hospital,Institution or Z City,Town or Village Johnsburg Town Street Address 10 Manor Road 17,Johnsburg Town, New York 12853 pManner of Death ©Natural Cause El Accident 0 Homicide Suicide El Undetermined Ej Pending Circumstances Investigation W Medical Certifier Name Title 0 Lynn Keil PA Address 1340 State Route 9,Lake George Town,New York 12845 Death Certificate Filed District Number Register Number City,Town or Village North Creek 5655 52 ElBurial Date Cemetery,Crematory or Facility Name 12/27/2021 Pine View Crematorium ElEntombment Address ElCremation Queensbury Town,New York ElDonation 0 ❑Removal Date Place Removed and/or and/or Held N Hold Address 0 a. Date Point of CO ❑Transportation p by Common Shipment Carrier Destination ElDisinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Barton-Mcdermott Funeral Home Inc 00141 Address 9 Pine St,Chestertown,New York 12817 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above 2 Address C W a' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/27/2021 Registrar of Vital Statistics 7(pth(eerr C.Gorah(ECectronicarry Signed) (signature) District Number 5655 Place North Creek, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition /',?''.ZC'2( Place of Disposition i J e (/;e, ) i ei 4.Jo r�C 2 (address) W (section) (lot n (grave number) 8 Name of Sexton or Person in Cha f Premises1i z / ,-/� (please print) W Signature "/' //A Title OP-ex-it-6 DOH-1555(07/18)p 1 of 2 • C' '"? 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#