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Grippo, John A. RX Date/Time 03/12/2020 11:35 7186556461 P,001 Mar 12 20,04:34p McKeon Funeral Home 7186556461 p.1 NEW YORK STATE DEPARTMENT OF H EALTH Burial -Transit Permit Bureau of Vital Records Name First Middle Last Sex John A Grippo Male Date of Death Age If Veteran of U.S.Armed Forces, D3109i2O2O 46 Years War or Dates H Place of Death ! Hospital.Institution or WCity,Town or Village Lake George Town Street Address 11 .lenkin Road,Lake George Town,New York 12845 C1 Mannerof Death Natural Cause Accident Homicide Suicide Undetermined ©Pending V Circumstances Investigation WQ Medical Certifier Name Title Connie Goedert Coroner Address 1400 St Route 9,Lake George Town,New York 12845 Death Certificate Fled Dislrict Number Register Number City,Town or Village Lake George 5651 1 Burial Date Cemetery,Crematory or Facility Name 0311 212 02 0 Pineview Crematory EntombmentAddress Cremation Queensbury,New York Donation zRemoval Date Place Removed and/or and/or Held l-fn Hald Address O a Date Point of W ❑Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home John F X Mckeon$Son Inc 00890 Address 3129 Perry Ave,Bronx,New York 10467 Name of Funeral Finn Making Disposition or to Whom Remains are Shipped,If other than Above Address l= W CL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03112)2020 Registrar of Vital Statistics rPatnciaPWcXinneySchuster(EfectronicaffySigncd) (signature) District Number 5651 Place Lake George, New York certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 1— Z Date of Disposition 3� Place of Disposition r j (f t" W /ad W U) /sedian/ (lot number) /grave number) cc /am/✓in Name of Sexton or Person in Charge of Premises —RA Y �' (please print! Z LLi Signature f Title r— OGH-1555(o7/t8)p tof 2 'ublic Health Law Sec. 4145(2b) 01,34247 teceipt iuman remains of delivered on , 20 T Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#