Persons, Jamie Allen it(......i
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NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
T-5.
Name First Middle Last Sex
Jamie Allen Persons Male
Date of Death Age If Veteran of U.S.Armed Forces,
06/12/2022 38 Years War or Dates
H Place of Death Hospital,Institution or
WCity,Town or Village Lake George Town Street Address 1912 New York 9 Route,Lake George Town,New York 12845
p Manner of Death ❑Natural Cause aAccident ❑Homicide Suicide nUndetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
O Connie Goedert Coroner
Address +r
1400 St Route 9,Lake George Town,New York 12845
Death Certificate Filed Town Of Lake George District Number Register Number
City,Town or Village 5651 13
Burial Date Cemetery,Crematory or Facility Name
06/21/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
g Removal Date Place Removed
- and/or and/or Held
F-- Hold Address
N
0
a Date Point of
U) Transportation Shipment
Q by Common
Carrier Destination
O
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander Baker Funeral Home 00037
Address
3809 Main St,Warrensburg,New York 12885
Name of Funeral Firm Making Disposition or to Whom
1... Remains are Shipped,If Other than Above
S Address
Q
W
D. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/15/2022 Registrar of Vital Statistics Patricia c1jMfc`I(inney-Scluster(ECectronica1TySigned)
(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:
Z `f W Date of Disposition (�1Z3I 2Z Place of Disposition
2 (address)
W
CC (section) i 'Vat number) (grave number)
SName of Sexton or Person in Charge of mises IA 4+ L � 'NiW►-i
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lease print) f irki�
W Signature Title ` �(
DOH-1555(07/18)p 1 of 2
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(t1 >.10t 8
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# ' '