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Neigh, Jackson NEW YORK STATE DEPARTMENT OF HEALTH E ` " 'A S Vital Records Section Burial - Transit Permit Name First Middle Last Sex Jackson D Neigh Male Date of Death Age If Veteran of U.S. Armed Forces, September 15, 2018 5 War or Dates Place of Death Hospital, Institution or tu City, Town or Village Argyle Street Address 769 Harper Road I Manner of Death ❑Natural Cause X❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ri❑ Pending iti # Circumstances Investigation t�l Medical Certifier Name Title [� Robert Lemieux, 4ROPCg_, Address 219 Pope Hill Road Argyle, NY 12809 Death Certificate Filed District Number c Register City, Town or Village Argyle J�s0 ❑Burial Date Cemetery or Crematory September 17, 2018 Pine View Crematory ",a Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z ❑ Removal and/or Held and/or Address Hold Date Point of ❑Transportation Shipment by Common Destination a Carrier Date Cemetery Address ❑ Disinterment Date Cemetery Address El Reinterment Permit Issued to Registration Number Name of Funeral Home M. B. Kilmer Funeral Home-Argyle 01077 Address 123 Main St., Argyle NY 12809 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address a' Permission is hereby granted to dispose of the human remains described above as indicated. • Date Issued 9I)i ) tao1 S Registrar of Vital Statistics &JLSLC, r',c. ,(..,--- (signature) District Number 515o Place Al)l< N.IU I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 09/17/2018 Place of Disposition Quaker Road Queensbury,NY 12804 (address) te (section) (lot number) (grave number) 0 Name of Sexton or Person in Charge of Premises /ln� pLr Stdvat (please print) sm Signature Title NE61Tat (over) DOH-1555 (02/2004)