Goodwin, Harold Stephen Jr. y
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records -
Name First Middle Last Sex
Harold Stephen Goodwin Jr Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/11/2023 86 Years War or Dates
i.,. Place of Death . Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
111
pManner of Death El Natural Cause Accident ❑Homicide Suicide Undetermined riPending
V I—ICircumstances Investigation
a111 Medical Certifier Name Title
Julian Marynczak 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 18
Burial Date Cemetery,Crematory or Facility Name
01/12/2023 1 Pine View Cemetery
Entombment Address
Cremation Queensbury Town,New York
DDonation
ZZ❑Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
d Date Point of
t/1❑Transportation
p by Common Shipment
Carrier Destination
Date Cemetery Address
Disinterment
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
1— Remains are Shipped,If Other than Above
2 Address
Q
UI
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/11/2023 Registrar of Vital Statistics Megan9'oiin(EJ ctronicall: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:
Ir
Z Date of Disposition I/13)13 Place of Disposition -F-,V.--- A,tiff._
2 (address)
W
CC N (section) (grave number/
aName of Sexton or Person in Charge of Premises Ar(lot,numberS40.
Z (pse print)
________7421
W Signature Title fir")IITCI(
DOH-1555(o7/18)p 1 of 2
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#