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Wilson, John NEW YORK STATE DEPARTMENT OF HEALTH 2 Vital Records Section Burial - Transit 'Permit ry Name First Middle Last Sex John William Wilson Male Date of Death Age If Veteran of U.S. Armed Forces, March 13, 2017 58 War or Dates n/a Place of Death Hospital, Institution or fig. City, Town or Village Glens Falls Street Address 23 Kenworthy Ave Manner of Death I X)Natural Cause n Accident n Homicide n Suicide n Undetermined ri Pending Circumstances Investigation ..k Medical Certifier Name Title ex Eric Pillemer MD Address f Glens Falls Hospital, 100 Park St, Glens Falls,NY 12801 — Death Certificate Filed District Number Register Number r< City, Town or Village Glens Falls 5601 11 ❑Burial Date Cemetery or Crematory ❑Entombment Address ©Cremation Date Place Removed O In Removal and/or Held and/or Address F Hold Cl) O Date Point of Nn Transportation Shipment p by Common Destination Carrier I I Disinterment Date Cemetery Address El Reinterment Date Cemetery Address Permit Issued to � �; Registration Number Name of Funeral Home Regan Denny Stafford Funeral Home 01443 Address 53 Quaker Road, Queensbury, NY 12804 G Name of Funeral Firm Making Disposition or to Whom 1�+' ' Remains are Shipped, If Other than Above Address f Permission is herebyy granted to dispose of the human remains described above as indicated. Date Issued 3l 15 l /'1 Registrar of Vital Statistics I; C.)\,Mnt\-X2- .-1\--1\--0,1Kit (signature) 0 District Number 5601 Place Glens Falls,e`)%,4 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z UJ Date of Disposition%/4/,i 7 Place of Disposition 2Zi a (/1f G,r 4 •y iti / (address) co 0 (section) i( (lot number) (grave number) ca Z Name of Sexton or P rs Charge of Premises _)t,,/;G,.,� W-[fie (please print) W Signature ff/ 4/1--. Title GCam zj-- �/ (over) DOH-1555(02/2004)