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Yates, William M • NEW YORK STATE DEPARTMENT OF HEALTH Burial- Transit Permit Bureau of Vital Records Name First Middle Last Sex William M.Yates Male Date of Death Age If Veteran of U.S.Armed Forces, 01/15/2022 71 Years War or Dates . Place of Death Hospital,Institution or WCity,Town or Village Thurman Town Street Address 204 Valley Road,Thurman Town,New York 12885 p Manner of Death ©Natural Cause Ei Accident El Homicide El Suicide El Undetermined El Pending LLJ Circumstances Investigation 0 Medical Certifier Name Title Ageel Gillani MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Athol 5659 ElBurial Date Cemetery,Crematory or Facility Name 01/19/2022 Pine View Crematory 0 Entombment Address ElCremation Queensbury Town,New York ElDonation 0 Removal Date Place Removed H and/or and/or Held N Hold Address 0 CL N ElTransportation 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 Alexander Baker Funeral Home 00037 Address 3809 Main St,Warrensburg,New York 12885 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped,If Other than Above 2 Address Q W Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/18/2022 Registrar of Vital Statistics Susan Staples(ECectronicalty Signed) (signature/ District Number 5659 Place Athol, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z uJ Date of Disposition i I Iq I 1Z Place of Disposition vim ( vrw—, 2 (address) W N CC (section) A (lot number) (grave number) Name of Sexton or Person in Charge of Pre s s A eti 1n�1� Z (pie e print) W Signature Title CM4q1741 DOH-1555(07/18)p 1 of 2 i Public Health Law Sec. 4145(2b) €`) 5 5 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#