McCall, Samuel Jr. NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permrt
Bureau of Vital Records
Name First Middle Last Sex
Samuel McCall Jr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
09/28/2022 85 Years War or Dates
F.. Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
,p Manner of Death Natural Cause Accident ❑Homicide Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
C Christopher Smith MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 498
Burial Date Cemetery,Crematory or Facility Name
09/29/2022 Pine View Crematory
Entombment Address
ZCremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
N Hold Address
0
O. Date Point of
N Transportation
p by Common Shipment
Carrier Destination
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
2 Address
CC
W
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/29/2022 Registrar of Vital Statistics Megan No(in(ECectronical(y Signed)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition ?pc/2 t Place of Disposition !—
W (address)
W
Nft (section) ft (lot number) (grave number)
g Name of Sexton or Person in Charge f Premises C q '" `tT
(pi se print)
W Signature Title nz��"/"t
DOH-1555(07/18)p t of 2
I:23_F28
Public Health Law Sec. 4145(2b)
Receipt
1 Human remains of delivered on , 20
I '
i
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#