Perry, Wayne E �4 u
N EW YORK STATE DEPARTMENT OF H EALTH � - `
Bureau of Vital Records Burlap - Transit Permit
Name First Middle Last Sex
Wayne E.Perry Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/11/2023 70 Years War or Dates
ZPlace of Death Hospital,Institution or
11J City,Town or Village Bolton Town Street Address 16 Bradley Lane,Bolton Town, New York 12814
p Manner of Death El Natural Cause Accident Homicide OSuicide DUndetermined TiPending
(Wj Circumstances Investigation
0 Medical Certifier Name Title
Ryan Donnelly DO
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Town Of Bolton District Number Register Number
City,Town or Village 5650 1
Burial Date Cemetery,Crematory or Facility Name
01/14/2023 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
DDonation
oRemoval Date Place Removed
E= and/or and/or Held
Hold Address
0
d. Date Point of
Cl)❑Transportation
by Common Shipment
Carrier Destination
ODisinterment 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
H Remains are Shipped,If Other than Above
Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/13/2023 Registrar of Vital Statistics Jodi Petteys(Electronically Signed)
(signature)
District Number 5650 Place Town Of Bolton
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
IL Date of Disposition JN-23 Place of Disposition � e,,j CrGjtp c�
2 (address)
W
CC N (section) (loAnu� (grave number)
0 Name of Sexton or Person in Charge of miles A�/Yfa,-,,1,
Z (please print)
W Signatures �� Title cer.�
DOH-1555(07/18)p 1 of 2
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Public Health Law Sec. 4145(2b)
1
iReceipt
1 .iHuman remains of �` fr delivered on , 20'
1
1
1 Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
1