Backus, Deane Lynn NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle , ' ; Last Sex
Deane Lynn Backus Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/02/2023 80 Years War or Dates
Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation
W Manner of Death ❑X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
Courtney Diamond NP
Address
170 Warren St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 567
L Burial Date Cemetery,Crematory or Facility Name
12/08/2023 Pine View Cemetery
Entombment Address
Cremation Queensbury Town,New York
Donation
ZO❑Removal Date Place Removed
and/or and/or Held
Hold Address
N
0
d Date Point of
(/)OTransportation
p by Common Shipment
Carrier Destination
EIDisinterment Date Cemetery Address
111 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
a Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/06/2023 Registrar of Vital Statistics Megan Wolin(ECectronicaITy 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 j2. , ,23 Place of Disposition ,->7/ t.G/(e.e �,d �(�CC�75 r�/ fV� /o?f�U
2 (address)
W S�ncccd 9A
N (section) (lot number) (grave number)
gName of Sexton or Person in Charge of Premises C _onnd`c 6v Cci<.Q t
Z (please print)
W Signature Title J t i � r.-� i�ck.14
DOH-1555(07/18)p i of 2
1174O7
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pfne View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
CAMERON
LFLot No. 19-A
Address 44 Dean Rd. Hudson Falls NY 12839 Section No.
Owner David & Mary Lou Cameron Plot Seneca
Date 11/4/02
Approx. 200 Superficial ft. @
Location Bounded on North by Gavin, Winchell , Nooney & Vacant , South by
Vacant , East by Path, West by Path.
Corner Posts
Remarks 912_10 I1$ rlp Thorti.e " � � �hr S P a p at
Deed No. (and changes) 3204
Payment Record Paid in Full 11/4/02 (&2 , 400. 00)
Record of Interments �`�
t � JIa_�`jc NC"/14-1 trA,-i+,li:
32 ANGELINE POLIHROM 5/31/06 n �S Q
f
4 4_ x x x �-
'' Jonathan M. Cameron 11/7/02
�� � / , a2 3 V .S
V Cam- „
Form No. 01
BACKUS
NAME Dean Backus (L— * Age:
Lot Owner: David & Mary Lou Cameron
Lot# Seneca 19 A Grave# 1
Case: Concrete
Died: 1 2 .2.2 3 Interred: 1 2.8.2 3
Funeral Home: Baker FH
Cemetery: Pine View