Mattison Sr., James NEW YORK STATE DEPARTMENT OF HEALTH
Vital Vital Records Section Burial - Transit Permit
. Name First Middle Last Sex
James E Mattison Sr Male
Date of Death Age If Veteran of U.S.Armed Forces,
08/06/2018 77 Years War or Dates
I— Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
WManner of Death El NaturalCause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
W Medical Certifier Name Title
0 Maxime Berube MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 377
❑Burial Date Cemetery or Crematory
08/09/2018 Pine View Crematory
❑Entombment Address
,,®Cremation Queensbury, New York
Date Place Removed
Z❑Removal and/or Held
and/or Address
a Hold
Date Point of
l'a El Transportation Shipment
a by Common Destination
; Carrier
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
1.6 Remains are Shipped, If Other than Above
a Address
, Permission is herebygranted to dispose of the human remains described above as indicated.
p
Date Issued 08/09/2018 Registrar of Vital Statistics l96ertA Curtis(ECectronicatty Signed)
(signature)
District Number 5601 Place Glens Falls, New York
t, I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tu Z Date of Disposition (I fM (ia Place of Disposition ,i,ad L
w
M (address)
COIIJ
IIe (section) (lot nu/pber) (grave number)
•a Name of Sexton or Person in Charge of Premises 1 iri4 S i.' M'
Z (please print)
SignatureIli 4 Title
(over)
DOH-1555(02/2004)