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Adams Jr, John NEW YORK STATE DEPARTMENT OF HEALTH e 1 --- Vital Records Section Burial - Transit Permit Name First Middle Last Sex John Leland Adams Jr. Male Date of Death Age If Veteran of U.S. Armed Forces, January 20, 2017 42 War or Dates I- Place of Death Hospital, Institution or w W City, Town or Village Glens Falls Street Address Glens Falls Hospital W '�"Manner of Death atural Cause ElAccident ElHomicide ❑ Suicide ❑ Undetermined ❑ Pending ( Circumstances Investigation W Medical Certifier Name Title CI 3U r> I t -p-;c 5-ek'\ 17?iD Address / Q )a r lL :S _ /f.r7 S T /l'S /t/�/ /2 r G)/ Death Certificate Filed District Number Register Nurnber I)Town or Village Glens Falls : -6-1 ❑Burial Date Cemetery or Crematory January 24, 2017 Pine View Crematory ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z ❑ Removal and/or Held Q and/or Address r._ Hold N Date Point of a ❑Transportation Shipment Cl) by Common Destination 3 Carrier Date Cemetery Address El Disinterment Date Cemetery Address El Reinterment Permit Issued to Registration Number Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079 Address 82 Broadway, Fort Edward NY 12828 Name of Funeral Firm Making Disposition or to Whom I- Remains are Shipped, If Other than Above 2 Address re w a Permission is hereby granted to dispose of the human rer wins de cribed ab ve as in icated. Registrar of Vital Statistics Date Issued �; �TrP�.'-i� �� -/,2t-e , -(signature) District Number ,�(6,6 f Place f/ >7 I certify that the remains of the decedent identified above were disposed of in accordance th this permit on: W Date of Disposition 01/24/2017 Place of Disposition Quaker Road Queensbury,NY 12804 2 (address) W � (section) /�. (lot number) (grave number) a Name of Sexton or Person in Charge of remises 6 'r-s{ 1r Stinc7 ( ease print) W Signature Title CRE MtITV (over) DOH-1555 (02/2004)