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Paddock, John NEW YORK STATE DEPARTMENT OF HEALTH ` /0d Vital Records Section , Burial - Transit Permit is Name First Middle Last ' Sex John P. Paddock Male Date of Death Age If Veteran of U.S. Armed Forces, June 12, 2017 76 yrs. War or Dates n/a Place of Death Hospital, Institution or City, Town or Village Fort Ann Street Address 1 7A Oueen Anne Dr. Manner of Death©Natural Cause Accident Homicide Suicide Undetermined Pending Circumstances Investigation to Medical Certifier Name Title 0 Charles Yun, MD. Address k. 102 Park St_ , Glens Falls NY.. 12801 " '= Death Certificate Filed District Dumber Register Number '' 3 City, Town or Village Fort Ann 5723 1 Date Cemetery or Crematory ❑Burial June 13, 2017 PineView Crematorium Address x Cremation Queensbnry, NY_ 12804 Date Place Removed 0 Removal and/or Held n and/or Address FAHold 0 Date Point of N❑Transportation Shipment a by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address iiig Permit Issued to Registration Number Name of Funeral Home Mason Funeral Home 0111 7 3 Address P.O. Box 277, Fort Ann, NY. 12827 N• ame of Funeral Firm Making Disposition or to Whom irj Remains are Shipped, If Other than Above A• ddress ii IL Permission is hereby granted to dispose of the human re ins described ab s indicated. iiil Date Issued t-/3' /7 Registrar of Vital Statistics t �� '2 (sign ure) District Number 5723 Place Vi 1 l agP of Fart- Ann, NY. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: WD• ate of Disposition ON In Place of Disposition 1'h'V tr+mil°CIs 2 (address) LLJ N CC (section) ,j(lot number)r (grave number) 2 Name of Sexton or Person in Charge of Premi es , rg trice, j WAtiit gdi (please print) W Signature Title CJ2it.+eit-RA (over) DOH-1555 (9/98)