Osborne Jr., Gordon Lee vg
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Gordon Lee Osborne Jr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/10/2022 64 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address 118 Mud Pond Road,Queensbury Town, New York 12804
W
p Manner of Death ❑X Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined Pending
lL C.) Circumstances Investigation
LLI C Medical Certifier Name Title
Donald Merrihew MD
Address
319 Bay Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 12
❑Burial Date Cemetery,Crematory or Facility Name
01/13/2022 Pine View Crematory
ID Entombment Address
Q Cremation Queensbury Town,New York
▪Donation
Removal Date Place Removed
and/or and/or Held
H Hold Address
0
O. Date Point of
t/) ❑Transportation
CI Common Shipment
Carrier Destination
ElDisinterment Date Cemetery Address
Reinterment 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
�_ Remains are Shipped,If Other than Above
5. Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/13/2022 Registrar of Vital Statistics Carolinexdiegard Barb'er(/'ctranicaf SWnedl)
(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 i//412Z Place of Disposition Fn-giL.0IJJ
2 (address)
W
N CC (section) (lot number) (grave number)
Ili �,
0 Name of Sexton or Person in Charge o Premises n1 �tN
Z (pie e print)
W Signature Title CM"4113it
DOH-1555 l07/18)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#