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Whiting Jr., Jeffrey L 'Clint Z Tr. NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Jeffrey L.Whiting Jr. Male Date of Death Age If Veteran of U.S.Armed Forces, 03/20/2023 44 Years War or Dates H Place of Death Hospital,Institution or Z City,Town or Village Chester Town Warren Street Address 443 Olmstedville Road,Chester Town Warren,New York 12853 LLI p Manner of Death ZNatural CauseAccident 0 Homicide OSuicide Undetermined nPending U Circumstances Investigation Q Medical Certifier Name Title Lynn Keil PA Address 1340 State Route 9,Lake George Town,New York 12845 Death Certificate Filed Town Of Chester District Number Register Number City,Town or Village 5652 3 `Burial Date Cemetery,Crematory or Facility Name 03/23/2023 Pine View Crematory _Entombment Address ©Cremation Queensbury Town,New York Donation Z Date Place Removed 0Z Removal and/or Held H and/or -- Hold Address 0 a Date Point of V) Transportation p by Common Shipment Carrier Destination Date Cemetery Address ❑Disinterment - Date Cemetery Address El Reinterment 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 5 Address CC W n' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/22/2023 Registrar of Vital Statistics Mindy Conway(E(ectronwal(y 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: I � Date of Disposition 3)23J73 Place of Disposition -1'r,,,`/,., , ._ r,v,` 2 (address) ICJ; N CC (section) i (lot number) c, (grave number) • Name of Sexton or Person in Charge of Pre ' es /4. L. ,h' W ,/ Piase print/ .e :L Signature TitleaWit Tpt DOH-1555(018)p 1 of 2 r., 4 I `.7 $y Public Health Law Sec. 4145(2b) Receipt Human remains of w, delivered on , 20 Pine View Cemetery Repregenting the funeral home named on burial permit Official Funeral Directors Reg.or License#