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Tait, Keith Douglas
111 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Keith Douglas Tait Male Date of Death Age If Veteran of U.S.Armed Forces, 02/09/2023 66 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Chester Town Warren Street Address 288 Perry Road,Chester Town Warren, New York 12853 Manner of Death ❑X Natural Cause Accident Homicide Suicide Undetermined Pending U Circumstances Investigation W Medical Certifier Name Title G Agee!Gillani MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed Town Of Chester District Number Register Number City,Town or Village 5652 1 Burial Date Cemetery,Crematory or Facility Name 02/13/2023 Pine View Crematory _Entombment Address ©Cremation Queensbury Town,New York Donation goRemoval Date Place Removed • and/or and/or Held H InHold Address 0 a Date Point of U) Transportation by Common Shipment Carrier Destination oDisinterment Date Cemetery Address OReinterment 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 Address Q W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/13/2023 Registrar of Vital Statistics 9Kintfy Conway(ECectronica1ty Signed) (signature) District Number 5652 Place Town Of Chester I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:on Z -" � _ W Date of Disposition 2�I`1 �j Place of Disposition 2 (address) W CC CC (section/ 1 (lot number) (grave number) gName of Sexton or Person in Charge of tnises � Z / (p ase print) Signature / Title DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) Receipt Human remains of ' delivered on , 20 1 Pig'View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#