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Szmada, Jan Xavier -1 19 NEW YORKSTATE DEPARTMENT OF HEALTH y., Burial - Transit Permi Bureau of Vital Records Name First Middle Last Sex Jan Xavier Szmada Male Date of Death Age If Veteran of U.S.Armed Forces, 10/01/2023 59 Years War or Dates Place of Death Hospital,Institution or • City,Town or Village Glens Falls Street Address Glens Falls Hospital p▪▪ Manner of Death Natural Cause Accident El HomicideSuicide Undetermined Pending Circumstances Investigation W Medical Certifier Name Title G Aaron Heckler PA 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 454 —Burial Date Cemetery,Crematory or Facility Name 10/03/2023 Pine View Crematory _Entombment Address ©Cremation Queensbury Town,New York Donation ❑Removal Date Place Removed and/or and/or Held - Hold Address 0 O. Date Point of f/) Transportation p by Common Shipment Carrier Destination 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 .- Remains are Shipped,If Other than Above 2 Address Q W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/03/2023 Registrar of Vital Statistics .Megan Nb1in(ECectronicalry 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: Z W Date of Disposition /0 S.' 2 Place of Disposition rive v riF_u Ells OQ lcoN1 (address) W N CC (section) i7 (lot number) c (grave number) 4//Lt 2 Name of Sexton or Person in Charge of remises (p/e se print) UJ l frA tt Signature Title DOH-1555(07/18)p 1 of 2 7,.. ,e A 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#