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Breault, Harold Earl Jr. NEW YORKSTATE DEPARTMENT OF HEALTH 't1 Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Harold Earl Breault Jr. Male Date of Death Age If Veteran of U.S.Armed Forces, 02/10/2022 71 Years War or Dates 1969-1972 i_ Place of Death Hospital,Institution or Z City,Town or Village Hudson Falls Village Street Address 219 Main Street Apt.5,Hudson Falls Village,New York 12839 0 Manner of Death © Natural Cause El Accident 0 Homicide ❑Suicide ❑Undetermined I=1 Pending W Circumstances Investigation W Medical Certifier Name Title 0 Robert Lemieux Coroner Address 415 Lower Main Street,Hudson Falls Village,New York 12839 Death Certificate Filed District Number Register Number City,Town or Village Hudson Falls Village 5726 5 ❑Burial Date Cemetery,Crematory or Facility Name 02/15/2022 Pine View Crematory ❑Entombment Address lCremation Queensbury Town,New York ❑Donation ZEl Removal Date Place Removed and/or and/or Held F- Hold Address to 0 Date Point of to �Transportation Shipment Q by Common Carrier Destination El Disinterment 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 I—. Remains are Shipped,If Other than Above 2 Address CC W EL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/15/2022 Registrar of Vital Statistics Cynthia ABarcfin(ECectronicaCCySigned) (signature) District Number 5726 Place Hudson Falls Village, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:'FIN �/� Z Date of Disposition x'MU. Place of Disposition ,,.,y_ /,../4UI:�--... 2 (address) W CC (section) //l (lot number) (grave number/ 0 Name of Sexton or Person in Charge of Premises ` ll1 t`'� _number) .— Mk Z please print/ W Signature �jl _ Title �aktV"f�� DOH-1555(07/18)p 1 of 2 01a 16 Public Health Law Sec. 4145(2b) Receipt Human remains of '+ r, delivered on , 20 Pine View Cemetery Representing4ie funeral home named on burial permit Official Funeral Directors Reg. or License#