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Canon, George NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit 3: Name First Middle Last Sex George W. Canon Male Date of Death Age If Veteran of U.S. Armed Forces, 0 6/1 8/2 01 7 7`8-__ War or Dates Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death 0 Natural Cause 0 Accident 0 Homicide 0 Suicide ri Undetermined 0 Pending W Circumstances Investigation W Medical Certifier Name Title MD 1 William Cleaver Address 100 Park St. Glens Falls NY 12801 Death Certificate Filed District Number Register Number City, Town or Village Glens Falls CC (j c) 1 q Date Cemetery or Crematory ❑Burial 0 6/2 0/2 01 7 Pine View Crematory ❑Entombment Address ®Cremation Quaker, Rd. Quaens ry, NY Date F e Removed kri Removal E. ;or Held (2 and/or Address I Hold VI O Date Point of i Transportation Shipment a by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Ciiii Permit Issued to Registration Number Name of Funeral Home Edward L Kelly FH 0051 9 Address Schroon Lake, NY r2$70 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above • Address itr ILI IL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 6/ Z©//7 Registrar of Vital Statistics UV O k,), V (signatu District Number 3�tt' Place 6M Fe& '\ S/ PJ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ILI Date of Disposition Col/0 in Place of Disposition f mciL eCrndor4JN., ,'g (address) LEE ♦O CC (section) (lot number) r (grave number) ta Name of Sexton or Person in Charge of Premises i'�s Jt""tl Z ( ease print) Signature //L �'` Title ��E� (over) DOH-1555 (02/2004)