Zura, George William F it 11 YZ-
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Recordsdirat Burial - Transit Permit
Name First Middle Last Sex
George William Zara Male
Date of Death Age If Veteran of U.S.Armed Forces,
05/2812022 60 Years War or Dates
p. Place of Death Hospital.Institution or
WCity,Town or Village Queenebury Town Street Address 547 Aviation Road,Queensbury Town,New York 12804
a Manner of Death El Natural Cause Accident 0 Homicide ❑Suicide ❑Undetermined riPending
ILI
Circumstances Investigation
aMedical Certifier Name Title
Timothy Murphy Coroner
Address
52 Havlland Avenue,Glens Falls,New York 12801
Death Certificate Filed Town Of Quesnsbury District Number Register Number
C ,Town or Vitt" 5657 89
Burial Date Cemetery,Crematory or Facility Name
06/02/2022 Pine View Crematory
Entombment Address
INCremation Queenebury Town,New York
Donation
MDRemoval Date `'I Place Removed
and/or and/or Held
a Hold Address
0
Transportation Datey=1
Point of
by Common Shipment
Carrier Destination
Date Cemetery Address
❑Disinterment
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
-. Remains are Shipped,If Other than Above
2 Address
gr
W
a. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/02/2022 Registrar of Vital Statistics Carane.9ilAyaras ararivreErsatvnicadj,304
(signature)
District Number 5657 Place Town Of Queenebury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: '/ AA
~ IL U`t�
W Date of Disposition f0 13�1'Z Place of Disposition ,nt
a (address)
W
CC CC (section) g (let number) (grave number)
Sqvi8 Name of Sexton or Person in Charge of Premises inAr.iL. ii-t-
z (p ere print)
W Signature L=/( /s� Title re# H(7
DOH-1555(07/18)pi of 2
I ) 1 rS 7.t.. . 5 .
Public Health Law Sec. 4145(2b)
Receipt
Human remains of /_- _ ` delivered on ; 20.
k
r.. y )' i
i
Pine View Cemetery Representing the funeral home name&on burial permit
Official Funeral Directors Reg.or License-# - '