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DuPuis, Jason M. NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Jason M DuPuis Male Date of Death Age If Veteran of U.S.Armed Forces, 03/30/2020 39 Years War or Dates Place of Death Hospital,Institution or WCity,Town or Village Queensbury Town Street Address 27 Boulevard,Queensbury Town,New York 12804 0 Mannerof Death ❑Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ©Pending Uj Circumstances Investigation WMedical Certifier Name Title Connie Goedert Coroner Address 1400 St Route 9,Lake George Town,New York 12845 Death Certificate Filed District Number Register Number City,Town or Vi Rage Queensbury 5657 60 ❑Burial Date Cemetery,Crematory or Facility Name 04/03/2020 Pine View Crematory ❑Entombment Address X❑Cremation Queensbury Town,New York ❑Donation 0 Removal Date Place Removed and/or —7and/or Held NHol.d Address O t1 Date Point of U) ❑Transportation Shipment p by Common 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 F.. Remains are Shipped,If Other than Above Address 1X W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 04/03/2020 Registrar of Vital.Statistics Caroline-51fiCdegarde Barber(ECectronicalTy 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 y 13 1 U Place of Disposition LU (address) W N (section) (lot number) (grave number) SName of Sexton or Person in Charge of remises Z (p se print W Signature Title DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) r 013499 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#