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Green, William Jonathan #fgzo NEW YORKSTATE DEPARTMENT OF HEALTH cF � - Bureau of Vital Records BurialTransit Permit Name First Middle Last Sex William Jonathan Green Male Date of Death Age If Veteran of US.Armed Forces, 10/06/2023 71 Years War or Dates F. Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital p• Manner of Death �Natural Cause Accident ❑Homicide Suicide Undetermined Pending Circumstances Investigation W Medical Certifier Name Title f0 Lynn Keil PA Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed City Of Glens Falls District Number Register Number City,Town or Village 5601 471 ElBurial Date Cemetery,Crematory or Facility Name 10/11/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York Donation 6❑Removal Date Place Removed and/or and/or Held F Hold Address N 0 O. Date Point of f/)ETransportation p by Common Shipment Carrier Destination IIDisinterment 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 1— Remains are Shipped,If Other than Above 2 Address IX W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/11/2023 Registrar of Vital Statistics MeganWain(E(ectronicaltySigned) (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 iW Date of Disposition /0 113173 Place of Disposition rINEviGJ tPei1eer/Qydl'N 2 (address) W NCE (section) (lot number) (grave number) 8 Name of Sexton or Person in Charge of Premix _ �r . mti i 1seprint) W Signature Title TP t. DOH-1555(07/t8)p 1 of 2 Public Health Law Sec. 4145(2b) ..5,. `# 3 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg. or License# )