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Maxwell, Thomas Fred NEW YORK STATE DEPARTMENT OF HEALTH CLF\ Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Thomas Fred Maxwell Male Date of Death Age If Veteran of U.S.Armed Forces, 03/09/2024 64 Years War or Dates F,. Place of Death Hospital,Institution or W City,Town or Village Glenville Town Street Address 431 Ballston Road#1,Glenville Town, New York 12302 p• Manner of Death ❑X Natural Cause Accident 0 Homicide Suicide Undetermined Pending U Circumstances Investigation 0▪ Medical Certifier Name Title Nadarajah Balasubramaniam ME Address 1101 Nott Street,Schenectady,New York 12308 Death Certificate Filed Town Of Glenville District Number Register Number City,Town or Village 4651 36 Burial Date Cemetery,Crematory or Facility Name 03/12/2024 Pine View Crematory Entombment Address ©Cremation Queensbury,New York Donation Removal and/or Date Place Removed and/or Held H Hold Address N 0 O. Date Point of (/) 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 H Remains are Shipped,If Other than Above 2 Address Q W n' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/12/2024 Registrar of Vital Statistics Julie Davenport(Electronically Signed) (signature) District Number 4651 Place Town Of Glenville I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I— w Date of Disposition 31 iy 124 Place of Disposition f'r' vcF... iiC evier 2 (address) W CC N (section) /7 /(lot number) (grave number) 8 Name of Sexton or Person in Charge of P ise .. G l- - 'ft Z 'ease print) fW Signature Title (PE MAPie DOH-1555(07/18)p t of 2 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#