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Pearson, Jacques M7 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Jacques Charles Pearson Male Date of Death Age If Veteran of U.S. Armed Forces, December 28,2017 74 War or Dates Place of Death Hospital, Institution or City, Town or Village Lake George Street Address 77 East Schroon River Road Manner of Death n Natural Cause n Accident Homicide Suicide Undetermined Pending Circumstances Investigation Medical Certifier Name Title 0" Aqeel Gillani Address CR Wood Cancer Center, 102 Park St.,Glens Falls,NY 12801 ;' Death Certificate Filed District Number Register Number City, Town or Village Lake George 5651 ❑Burial Date Cemetery or Crematory January 2,2018 Pine View Crematory II Entombment - Address ©Cremation 21 Quaker Rd., Queensbury, NY 12804 Date Place Removed Z I I Removal and/or Held and/or Address H Hold Cl) 0 Date Point of N Transportation Shipment a by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address ' V d Permit Issued to Registration Number Name of Funeral Home Alexander-Baker Funeral Home 00037 ', Address 3809 Main Street,Warrensburg,NY 12885 Name of Funeral Firm Making Disposition or to Whom i. Remains are Shipped, If Other than Above Address AZ AU #t• Permission is hereby grant d to dispose of the human remains described a ove a indicated. Date Issued — - Registrar of Vital Statistics rIckCX 0 , Ignatur District Number 5651 Place Lake George I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: tu Date of Disposition 1/3)Ig Place of Disposition f.ri,. - 2 (address) W CO rt (section) pot number) (` (grave number) QName of Sexton or Person in Charge of Premises thh,ty.- J 1.-tUt Z (ppllease print) Signature 4 '.r Title (OA tt-10i?_ (over) DOH-1555 (02/2004)