Baker, Clay Anthony 11 7(
NEW YORKSTATE DEPARTMENT OF HEALTH osso Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Clay Anthony Baker II Male
Date of Death Age If Veteran of U.S.Armed Forces,
02/21/2022 45 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Albany Street Address Albany Medical Center Hospital
11.1
p Manner of Death ❑X Natural Cause ❑Accident 1=I Homicide ❑Suicide Undetermined Pending
V Circumstances Investigation
W Medical Certifier Name Title
a Michael Kuna
Address
43 New Scotland Ave,Albany,New York 12208
Death Certificate Filed District Number Register Number
City,Town or Village Albany 0101 0500
❑Burial Date Cemetery,Crematory or Facility Name
02/24/2022 Pine View Crematory
❑Entombment Address
gCremation Queensbury Town,New York
❑Donation
Z Removal Date Place Removed
and/or and/or Held
• Hold Address
0
d Date Point of
• ❑Transportation Shipment
Q by Common
Carrier Destination
Date Cemetery Address
ElDisinterment
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
t.. Remains are Shipped,If Other than Above
2 Address
W
▪ Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/24/2022 Registrar of Vital Statistics DDanielk5 cillerpre gYectronicalTy Signed)
(signature)
District Number 0101 Place Albany, 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 if ZS in Place of Disposition
(address)
ILLI
N re (section) `/fn
®(lot number) (grave number)
Name of Sexton or Person in Cha •�� Premises A L
(pleas//print)
W Signature Title
DOH-1555(o7/18)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#