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Emmanuel, Ephraim Victor NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records (LF Name First Middle Last Sex Ephraim Victor Emmanuel Male Date of Death Age If Veteran of U.S.Armed Forces, 02/04/2024 69 Years War or Dates National Guard H Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital pManner of Death ❑X Natural Cause Accident El Homicide 0 Suicide Li Undetermined Pending tU Circumstances Investigation W Medical Certifier Name Title CI Mathew Varughese DO 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 72 Burial Date Cemetery,Crematory or Facility Name 02/06/2024 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 a Date Point of Cl) Transportation Shipment Q by Common Carrier Destination Disinterment Date Cemetery Address ElReinterment 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 2 Address Q W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/06/2024 Registrar of Vital Statistics Megan Wolin(E(ectronically 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: / Date of Disposition -6 Q��� Place of Disposition r ` Aie V i e,,v c a 2 (address) W /Cl) (section) (lot number/ (grave number) cc gName of Sexton or Person in Charge Premises 6e1")Y/))1/.-li J fi/''' Z , (please print) W Signature >�/ /,��i Title Q -��i`r`�` DOH-1555(07/18)p 1 of 2 • f.. 1 7 c r 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#—