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Gregory, James A. NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex James A Gregory Male Date of Death Age If Veteran of U.S.Armed Forces, 12/01/2019 60 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Queensbury Town Street Address 8 East Avenue,Queensbury Town,New York 12804 pManner of Death © Natural Cause 1:1Accident Homicide Suicide Undetermined Pending W Circumstances Investigation yMedical Certifier Name Title o Connie Goedert Coroner Address 1400 St Route 9,Lake George Town,New York 12845 Death Certificate Filed District Number Register Number City,Town orViRage Queensbury 5657 178 ❑Burial Date Cemetery,Crematory or Facility Name 12/04/2019 Pine View Crematory Entombment Address Cremation Queensbury Town,New York Donation Removal Date Place Removed F and/or and/or Held Hold Address V1 Transportation Date Point of a by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan Denny Stafford Funeral Home 01443 Address 53 Quaker Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Otherthan Above Address W a" Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/04/2019 Registrar of Vital.Statistics Caroline MiCdegarde Barber(ECectronicaCCy Signed (signature! District Number 5657 Place Queensbury, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 12141 Place of Disposition V..,rUJI (address) W (A (section/ (tot number/ (grave number/ 8 Name of Sexton or Person in Charge of Premise ase �j� ( ease print/ W Signature /�^/(/ �(,s^ Title r n- DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 3127 Receipt Human remains of delivered on , 20 Pine View Cemetery Represeiitmg the N eral home named on burial permit Official Funeral Directors"Reg.or License#