Copeland Jr., Benjamin , 4 3 s3
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
iiie Name First Middle Last Sex
Benjamin T,_ Copeland, Jr.. Male
iili;i Date of Death Age If Veteran of U.S. Armed Forces,
April 30, 2018 68 yrs. , War or Dates Vietnam Conflict
Place of Death Hospital, Institution or
City, Town or Village Fort Ann Street Address 1 218 Copeland Pond Rd.
tii
Manner of Death 0 Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
W Circumstances Investigation
Medical Certifier Name Title
Aqueel Gillani MD.
Address
102 Park St - , G1ens Falls NY_ 12801
~< Death Certificate Filed District Number Register Number
s City, Town or Village Fort Ann 5754 3
Date Cemetery or Crematory
❑Burial May 01 , 2018 Pi neView Crematorium
Address
®Cremation Quaker Rd. , Queensbury, NY. 129n
Date Place Removed
0❑Removal and/or Held
1�= and/or Address
a Hold
0 Date Point of
cani❑Transportation Shipment ___
5 by Common Destination
Carrier
El Disinterment Date Cemetery Address
❑Renterment Date Cemetery Address
giiii Permit Issued to Registration Number
iiiiiiiii Name of Funeral Home Mason Funeral Home 0111 7
M Address
iiiiiii 18 George St. , P.O. Box 277, Fort Ann, NY. 12827
"' Name of Funeral Firm Making Disposition or to Whom
mat Remains are Shipped, If Other than Above
Address
W
Permission is hereby granted to dispose of the human ridescribed above a 'cated.
5/01 /2018 Registrar '7��
iiii Date Issued of Vital Statistics �1' I. /
(signat )
iiiiiiiiiny /2F2. 7
s District Number 5754 Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f
5 Date of Disposition C/t 114 Place of Disposition ' LL aj.-.
2 (address)
14
co
cr (section) ,41(lot,number)r (grave number)
0 Name of Sexton or Person in Charge of Premises /�*„6L �1'-At
z (please print)
iE i..,..,:r.Signature UTitle I'ii ID L
(over)
DOH-1555 (9/98)