Mansfield, James qi )
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records __„9`
Name First Middle Last Sex
James Mansfield Male
Date of Death Age If Veteran of U.S.Armed Forces,
11/02/2022 78 Years War or Dates 1961-1962
Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address Glens Falls Hospital
'p Manner of Death ❑X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
Kelly Maley PA
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 558
Burial Date Cemetery,Crematory or Facility Name
11/04/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
(Donation
0 Removal Date Place Removed
and/or and/or Held
H Hold Address
0
d Date Point of
U) 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
F— Remains are Shipped,If Other than Above
2 Address
Q
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/04/2022 Registrar of Vital Statistics Megan.Nolin(ECectronicaCCySigned)
(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:
W Date of Disposition //-'s-ZOZ2 Place of Disposition Pd1Q v' erze—45/sey
(addree
IiI
CC N (section/ (lot number) (grave number)
SName of Sexton or Perso Cha of Premises " t"'(14,1,1 4 wic'`4J,,e
Z (please print)
Signature 01� Title /e-''"4,Je) 4. /0/-4�
DOH-1555(07/18)p t f 2
J ,_. bey
Public Health Law Sec. 4145(2b)
1
Receipt
Human remains of delivered on , 20
Pine View Cemetery+. Representing the funeral home named on burial permit
Official Funeral Directors Reg. or License#