Sefren, James William 1- F) ft 271
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
James WiNiam Sefren Male
Date of Death Age If Veteran of U.S.Armed Forces,
03/26/2022 78 Years War or Dates 1965-1968
F— Place of Death Hospital,Institution or
Z City,Town or Village Lake George Town Street Address 24 Kirker Drive,Lake George Town,New York 12845
ILI
0 Manner of Death Ei Natural Cause ❑Accident 0 Homicide Suicide ❑Undetermined ❑Pending
UCircumstances Investigation
GGGW Medical Certifier Name Title
Ageel GNlani MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed Town Of Lake George District Number Register Number
City,Town or Village 5651 7
RBurial Date Cemetery,Crematory or Facility Name
03P29/2022 - Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
nDonation
goRemoval Date Place Removed
and/or and/or Held
pN Hold Address
0
O. Date Point of
CD El Transportation
a by Common Shipment
Carrier Destination
ElDisinterment 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
-. Remains are Shipped,If Other than Above
•'� Address
OC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03r29/2022 Registrar of Vital Statistics DztluraRAfc ine}"Sch rgkctmni.a.451SigecV
(signature/
District Number 5651 Place Town Of Lake George
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 3421 I Z Z Place of Disposition Fat—,
rt_
2 (address)
W
to
OC (section) d (lot number) (grave number)
2 Name of Sexton or Person in Charge of Premises Zr't �.ltii'
z ( ease print)
fW Signature —�i — Title ��fMonik
DOH-1555(07/18)p tot 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#