Rainsberger, Maximus Derain • a .
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Maximus Derain Rainsbe er Male
Date of Death Age If Veteran of U.S.Armed Forces,
02/06/2022 18 Years War or Dates
F Place of Death Hospital,Institution or
2 City,Town or Village Chester Town Warren Street Address 50 Kingsley Lane,Chester Town Warren,New York 12817
p• Manner of Death 0 Natural Cause El AccidentHomicide Suicide ❑Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
a 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 Chestertown 5652 2
ElBurial Date Cemetery,Crematory or Facility Name
02/08/2022 Pine View Crematorium
ElEntombment Address
EjCremation Queensbury Hamlet,New York
ElDonation
ElRemoval Date Place Removed
and/or and/or Held
H Hold Address
N
0
Lt. Date Point of
(A ❑Transportation
ES Common Shipment
Carrier Destination
Disinterment 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
CC
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/08/2022 Registrar of Vital Statistics Mindy Conway(ECectronica1ySigned)
(signature/
District Number 5652 Place Chestertown, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
IF-
W Date of Disposition ,L- ?-7' Place of Disposition Pjpt lit W (,('e,,41c40r�/
2 (address)
W
cc (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises Ttrihv y S tvi rc,5
Z (please print)
W
Signature Title c ie,,N►
DOH-1555(07/18)p i of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of ° d'l'ered on , 20
Pine View Cemetery Representing the funeral home named on bunal_permit
Official Funeral Directors Reg.or License#