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Cleveland, Larry J NEW YORK STATE DEPARTMENT OF HEALTH / Bureau of Vital Records Burial _ Transit Permit Name First Middle Last Sex Larry J.Cleveland Male Date of Death Age If Veteran of U.S.Armed Forces, 07/11/2023 70 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Queensbury Town Street Address 18 Overlook Drive,Queensbury Town, New York 12804 Manner of Death Ei Natural Cause Accident Homicide Duicide Undetermined nPending V Circumstances Investigation W Medical Certifier Name Title O Christopher Mason DO Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed Town Of Queensbury District Number Register Number City,Town or Village 5657 111 Burial Date Cemetery,Crematory or Facility Name 07/14/2023 Pine View Crematory _Entombment Address ©Cremation Queensbury Town,New York Donation Z❑Removal Date Place Removed and/or and/or Held - Hold Address 0 O. Date Point of U) Transportation p by Common Shipment Carrier Destination o Disinterment Date Cemetery Address DReinterment 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 IW Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 07/13/2023 Registrar of Vital Statistics Caroline gadegarde Barber(ECectronically Signed) (signature) District Number 5657 Place Town Of Queensbury I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z 111 Date of Disposition ZjSZp�3 Place of Disposition 2 (address/ W CC (section) (lot nu ben (grave number) S Name of Sexton or Person in Ch a of r ses J< /M b LJO t) W Signature Title o GtSev4c DOH-1555(07/18)p 1 of 2 or Public Health Law Sec. 4145(2b) Receipt Human remains of j delivered on , , 20 • _. Pine View Cemetery Representing the funeral hone named on burial permit Official Funeral Directors Reg.or License#