Mangels, Jay Elliot 11 I
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of VitatRecords
Name First Middle Last Sex
Jay Elliot Mangels Male
Date of Death Age If Veteran of U.S.Armed Forces,
02/21/2022 68 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address 18 East State Street,Glens Falls,New York 12801
ILI
p Manner of Death ❑X Natural Cause ❑Accident ❑Homicide ❑Suicide El Undetermined ❑Pending
W C.) Circumstances Investigation
W Medical Certifier Name Title
O Christopher Mason DO
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 123
❑Burial Date Cemetery,Crematory or Facility Name
02/23/20.2 Pine View Crematory
0 Entombment Address ``
X❑Cremation Queensbury Town,New York
▪Donation
0 Removal Date Place Removed
and/or and/or Held
N Hold Address
0
O. 1-1 Date Point of
(/) ❑Transportation
p by Common Shipment
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
E.. Remains are Shipped,If Other than Above
Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/23/2022 Registrar of Vital Statistics Zoe Morgan gYectronicallySigned
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
Z Date of Disposition 'Z 4c/,.2022 Place of Disposition P�rtA_ �t Ire. 47
2 (address)
W
CC N
(section) (lot number) (grave number)
0
Name of Sexton or Per in arge of Premises 1`a4 w4(-A*e-
Z (please print)
W Signature Title C/'cr_..r►4,10/ ;VG'
DOH-1555(o7/t8)p t of 2
{j _1 L `.
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
1
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg. or License#