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Marcoux # 3b NEWYORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Jeffrey W.Marcoux Male Date of Death 764gYears If Veteran of U.S.Armed Forces, 01/10/2020 Waror Dates Viet Nam H Place of Death Hospital,Institution or WCity,Town or Village Glens Falls Street Address Glens Falls Hospital `p Manner of Death © Natural Cause ❑Accident �Homicide Fj Suicide �Undetermined �Pending U Circumstances Investigation QW Medical Certifier Name Title Kyle Leonard MD Address 100 Park St,Glens Falls, New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 24 ❑Burial Date Cemetery,Crematory or Facility Name 01/13/2020 Pine View Crematory Entombment Address Cremation Queensbury Town, New York Donation 0 Removal Date Place Removed and/or and/or Held H N Hold Address O o- Date Point of to ❑Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Brewer Funeral Home Inc 00211 Address 24 Church Street PO Box 500,Lake Luzerne, New York 12846 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above Address ric (L Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/13/2020 Registrar of Vital Statistics Robert Andrew Curtis(Electronically Signed) (signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: H Z Date of Disposition )q/70 Place of Disposition w ,„,4-,rw,,, (address) W N (section) (lot number) (grave number) 93 Name of Sexton or Person in Charge of Premises r seS O'4# Z /p ase print P W Signature J-6c, Title 6kilog DOH-1555(07/18)p 1 of 2 y Public Health Law Sec. 4145(2b) 01332 3 0 Receipt Human remains of a_ delivered on , 20 Pine View Cemetery Reprdsenting,fh�funeral home named on burial permit f' Official Funeral Directors Reg.or License# ,-