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Keith, Jody S \tra. NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records ' Name First Middle Last Sex Jody S.Keith Male Date of Death Age If Veteran of U.S.Armed Forces, 07/16/2023 60 Years War or Dates H Place of Death Hospital,Institution or W City,Town or Village Albany Street Address Albany Medical Center Hospital 0 Manner of Death ❑X Natural Cause Accident ti Homicide lilSuicide Undetermined r 1Pending 1/1 Circumstances Investigation W 0 Medical Certifier Name Title O Matthew Blanchard Address 43 New Scotland Ave,Albany,New York 12208 Death Certificate Filed City Of Albany District Number Register Number City,Town or Village 0101 1640 HBurial Date Cemetery,Crematory or Facility Name 07/18/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York Donation ZO❑Removal Date Place Removed and/or and/or Held ~ Hold Address N 0 Q. Date Point of (I) Transportation Shipment p by Common Carrier Destination lilDisinterment 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 F.. Remains are Shipped,If Other than Above a Address Q IL 0- Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 07/17/2023 Registrar of Vital Statistics Danie/%Scillespie(E:CectronicalTySigned) (signature) District Number 0101 Place City Of Albany I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: �,� H Z▪ Date of Disposition 11 ji t 13 Place of Disposition �,wv �-Jt`,^^ (address) W NCC (section) (lot l number) (grave number) gName of Sexton or Person in Charge of Pr ' es 4Z (plea a print) W freer-an 417g Signature Title DOH-1555(07/18)p 1 of 2 ri • ..�.:7 1... F 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#-? )'<