Gilbert, Jacob Adam '"1.- �` 4 q I l
Li)NEW YORK STATE DEPARTMENT OF HEALTH � Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Jacob Adam Gilbert Male
Date of Death Age If Veteran of U.S.Armed Forces,
11/09/2022 32 Years War or Dates
i_ Place of Death Hospital,Institution or
Z City,Town or Village Johnsburg Town Street Address 624 Peaceful Valley Road,Johnsburg Town,New York 12853
0 Manner of Death 0 Natural Cause Accident ❑Homicide Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
0 Lynn Keil PA
Address
1340 State Route 9,Lake George Town, New York 12845
Death Certificate Filed Town Of Johnsburg District Number Register Number
City,Town or Village 5655 28
Burial Date Cemetery,Crematory or Facility Name
11/19/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
o❑Removal Date Place Removed
and/or and/or Held
F- Hold Address
N
0
n. Date Point of
Li)❑Transportation Shipment
Q by Common
Carrier Destination
O
Disinterment
Date Cemetery Address
ElReinterment 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
5 Address
CC
W
IL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/18/2022 Registrar of Vital Statistics Jean IM Comstock(ECectronicalfySigned)
(signature)
District Number 5655 Place Town Of Johnsburg
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
-ati_ />
WDate of Disposition 11 11 tt Place of Disposition 1
2 (address)
W
CC CC (section) (lot number) (grave number)
SName of Sexton or Person in Charge -Premises C r,)'" cAli
Z (p�aseprint) -
11-0(1
Signature Title ��Ic>n�
DOH-1555(07/18)p 1 of 2
I
} 01686171
Public Health Law Sec. 4145(2b) { I
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#