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Klena, Gary Steven g --16' NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Gary Steven Klena Male Date of Death Age If Veteran of U.S.Armed Forces, 02/23/2024 69 Years War or Dates H Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation t1J Manner of Death Undetermined Pending W Natural Cause Accident Homicide Suicide g Circumstances Investigation W Medical Certifier Name Title C Leah Terry NP Address 4573 State Route 40,Argyle Town,New York 12809 Death Certificate Filed City Of Glens Falls District Number Register Number City,Town or Village 5601 109 Burial Date Cemetery,Crematory or Facility Name 02/23/2024 Pine View Crematory Entombment_ Address ©Cremation Queensbury Town,New York Donation ZO❑Removal Date Place Removed and/or and/or Held H Hold Address N 0 a. Date Point of f/) Transportation Eli 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 i— Remains are Shipped,If Other than Above S Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/23/2024 Registrar of Vital Statistics MeganNoCn(ECectronica(IySigned) (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 tU Date of Disposition 7 ^ ja.20 i.l Place of Disposition ?r)1a-i,1 TeiLdi L f e_en 440 2 (address) W CC N (section) (lot number) (grave number) j 8 Name of Sexton or Pe n in C arge of Premises --1'�v (96. 4 tom, ' �t W (please print) Signature Title t-re_.��- ',7 ,ele,7,A.--- DOH-1555(07/18 1 of 2 Public Health Law Sec. 4145(2b) so ,l1_P 004 Receipt Human remains of delivered on , 20 Fine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#