Bell, Benjamin John NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Benjamin John Bell Male
Date of Death Age If Veteran of U.S.Armed Forces,
03/19/2022 54 Years War or Dates
1— Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address Cronin Road 8111,Queensbury Town,New York 12804
`p Manner of Death El Natural Cause ❑Accident 0Hornicide ESuicide Undetermined ❑Pending
Circumstances Investigation
W Medical Certifier Name Title
0 Paul Bachman MD
Address
9 Carey Rd,Queensbury Town,New York 12804
Death Certificate Filed Town of Queensbury District Number Register Number
City,Town or Village 5657 59
Burial Date Cemetery,Crematory or Facility Name
03/23/2022 Pine View Crematory
Entombment Address
-Ekreniation ' Queensbury Town,New York
DDonation
Z Removal Date Place Removed
and/or and/or Held
E— Hold Address
N
0
0 Date Point of
CO Transportation
a by Common Shipment
Carrier Destination
ODisinterment Date Cemetery Address
ElReinterment 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
H Remains are Shipped,If Other than Above
2 Address
CC
IW
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/23/2022 Registrar of Vital Statistics CarotinexkaregankBar6er(EYectroni ,furred)
(signature)
District Number 5657 Place Town Of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H
Z Date of Disposition 3l2q 127 Place of Disposition ai lL ,(�t0- —
W address)
W
CCCC (section) 4 ,(lot number) (grave number)
t4
S Name of Sexton or Person in Charge of P mises I/t )QL clitv41.it
z (please print)
UJ Title kit itbit
Sign atu re
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#