Arquette, Ryan Michael NEW YORKSTATE DEPARTMENT OF HEALTH
Bureau of Vital Records `—
Burial - Transit Permit
Name First Middle Last Sex
Ryan Michael Arquette Male
Date of Death Age If Veteran of U.S.Armed Forces,
09/01/2022 33 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address 18 Newcomb Street,Queensbury Town,New York 12804
UJ
`p Manner of Death Natural Cause IllAccident Ei Homicide Suicide Undetermined Pending
Circumstances Investigation
W• Medical Certifier Name Title
Connie Goedert Coroner
Address
1400 St Route 9,Lake George Town,New York 12845
Death Certificate Filed Town Of Queensbury District Number Register Number
City,Town or Village 5657 126
Burial Date Cemetery,Crematory or Facility Name
09/07/2022 Pine View Crematory
Entombment Address
▪Cremation Queensbury Town,New York
▪Donation
o❑Removal Date Place Removed
and/or and/or Held
H Hold Address
CO
0
C- Date Point of
to❑Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
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
H Remains are Shipped,If Other than Above
M Address
CC
III)
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/06/2022 Registrar of Vital Statistics Caroline 2fiffeganle Barber(ECectronicallySigned)
(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:
-/7).
Z Date of Disposition q I l 1?i Place of Disposition i
(address)
W
CC CC (section) (lot num (grave number)
O Name of Sexton or Person in Charge of P ises
plase print)
W Signature Title rri r
DOH-1555(o7/t8)p 1 of 2
e
.f .L b 6.1.0
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# ` ` „ (`!