Randall, James Howard NEW YORK STATE DEPARTMENT OF HEALTH h i D)D
Vital Reocma Sell Burial - Transit Permit
'. Name First Middle Last Sx
James Homed Parcel Mak
Data of Dead Ape If Veteran of U.S. Ammd Forces,
September 152020 82 Wwor Dates
t Plxe of Death Hall ina0tu0on or
If�Rka C' ,Town or Ville Glens Falls Saeet Al era Glens Falls Hospital
Manner of Deal O Natural Cause Q Aflackit ❑ HDmidae ❑Suicida ❑ Undetemdned Pending
Circumstances Investigation
0 Medical Cal Name Title
Geome Small Dr
Addresser
6" Palmer Ave. Corigh NY 12822
Death Certificate Film District Number Register Number
Cmi, Town or VIIWW Glens Fells CEO d
❑Buaal Dste Cemetery orCrematory
Seltemither l], 2020 Pine View Cremafo
Ekes item Quakarar
er
®cremation OuekerRxtl Queenstouni,NY 12804
2 ❑ Removal Date PIave N Nam
Removal
p al Ada rex
E Hold
Date Pointof
$X Transpormon Shihoment
by Common Derummon
a Comer
Disinterment Data Camdery Address
E] Reinknoent Data Cemetery Almost
Permit lasued w Registaton Number
Name of Funeral Home M.B. IOIme'Fune2l Home SGF 01078
Address
136 Main Stxt South Giant Falls NY 12803
Name Ot Funeral Firm Making Disposition orro Wbom
t Remain are Shipped, If ONer than Above
Address
A. Pamiskii la heroby rentedtoalapoa&of the human oral irlMd hove eat I a.
Dafa lesu�� Regiahar of Vital SlatleNce a
µ el
DIaNd Numbs /�/ place
I cedlfy that me remains of Me deaden Henthed above sere disposed ofln aocmd arm this parmt cm
DdNoWdmmuton0W1Wm20 Placeof Dispasihon OualNa ROal Dueensbury,NY12800
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Name of SeMon or Person in C/h§/Re of Preml / N� Sav11„
Sgrature ^^ Tito ( avas Puts star*IDS
(over)
DOH-1555 (02J2o00)
wnco Heift>awa .414sfznf 014022
Receipt
Human repo iue of _ delivered on
Noe View Cemetery Representing the Yunerul home named on bwal permit
mcod Fureml Ulrechm,Reg arGauuN