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Dutcher, Herbert Ernest I i_. ..1(z5 11 LILILI NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Herbert Ernest Dutcher Male Date of Death Age If Veteran of;U.S.Armed Forces, 05/21/2023 67 Years War or Dates i_ Place of Death Hospital,Institution or W City,Town or Village Glens Falls Street Address Glens Falls Hospital p Manner of Death ❑X Natural Cause Accident Homicide ESuicide Undetermined ri Pending W Circumstances Investigation W Medical Certifier Name Title 0 Shahid Ahmed MD 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 266 Burial Date Cemetery,Crematory or Facility Name 05/24/2023 Pine View Crematory Entombment _ Address ©Cremation Queensbury Town,New York Donation ZO❑Removal Date Place Removed and/or and/or Held F Hold Address N 0 Date Point of U)Dransportation Shipment p by Common -- Carrier Destination 111 Disinterment Date Cemetery Address 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 i— 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 05/24/2023 Registrar of Vital Statistics Megan Wolin(Electronically 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: I— ST Date of Disposition I 210115 Place of Disposition f;:::AIL_. 4---., (address) W U)CC (section) // (lot number) (grave number) ltLl S Name of Sexton or Person in Charge of Premises L_ ter Z may. (lease print) W px Signature (� Titled DOH-1555 07/18)p 1 of 2 1 J � Public Health Law Sec. 4145(2b) Receipt IHuman remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#