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Belline Jr., John ' 4 g NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit w Name First Middle Last Sex «w`, John Belline Jr. Male til Date of Death Age If Veteran of U.S. Armed Forces, Li 06/05/2018 78 Years War or Dates Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death©Natural Cause ❑Accident ❑Homicide El Suicide riUndetermined ri Pending Circumstances Investigation ,• .£ Medical Certifier Name Title Farhana Kamal MD Ai Address DI 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 281 ❑Burial Date Cemetery or Crematory ❑ 06/07/2018 Pine View Crematorium Entombment 4 Address "i ,®Cremation Queensbury, New York Date Place Removed ❑ Removal and/or Held ' ' and/or Address = Hold Date Point of Q Transportation Shipment by Common Destination Carrier 11 Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Barton-Mcdermott Funeral Home Inc 00141 Address 9 Pine St,Chestertown,New York 12817 40 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address ey' Permission is hereby granted to dispose of the human remains described above as indicated. 02 Date Issued 06/06/2018 Registrar of Vital Statistics qZp6ertA Curtis(E(ectronicattySigned) (signature) District Number 5601 Place Glens Falls, New York KA I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: • R• Date of Disposition `/S�ly Place of Disposition f.U,, �r+�,'�or,�. (address) (section) j/ (lot number) c (grave number) Name of Sexton or Person in Charge of Premises ry�+,,,,r J o^."44 i, (� Print) (Print • Signature L--� Title171L (over) DOH-1555 (02/2004)