Mazoureix, Jacques NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
•> Name First Middle Last Sex
iiig .Tacques Mazoureix Hale
Date of Death Age If Veteran of U.S. Armed Forces,
March 22, 2017 84 yrs. War or Dates ' 54—' 56
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause 0 Accident ❑Homicide 0 Suicide El Undetermined El Pending
Circumstances Investigation
Medical Certifier Name Title
#•• Shahid Ahmed MD.
Address
100 Park St. , Glens Falls, NY. 12801
Death Certificate Filed District Number Register/Jttl� r
Iii«> City, Town or Village Glens Falls 5601 l ,�`�"
Date Cemetery or Crematory
El Burial March 22, 2017 PineView Crematorium
Address
[ Cremation Queensbury, NY. 12804
Date Place Removed
2 Removal and/or Held
-- and/or Address
aHold
0 Date • Point of
N0 Transportation Shipment
a by Common Destination
HE Carrier
Disinterment Date Cemetery Adders..
Reinterment Date Cemetery Address
4777
Permit Issued to Registration Number
INI Name of Funeral Home Mason Funeral Home 01117
Il Address
P.O. Box 277, Fort Ann, NY. 1282P7
Name of Funeral Firm Making Disposition or to Whom
' .RRemains are Shipped, If Other than Above
Address
IN Permission is hereby granted to dispose of the human remains described above as indicated.
gili Date Issued 3/2 2/1 7 Registrar of Vital Statistics IIIIIIII �Jv a
(signature
111 District Number 5601 Place City of Glens Falls, NY.
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f-
W Date of Disposition.�f 2�/7 Place of Disposition �i'ha ()i Cud Z-.' ,h,�o y
2 // (address)
LU
U3
CC (section) ( (lo number) (grave number)
0 Name of Sexton or erson . Charge of Premises 1-t /;c- -t 4.i.ie.,_c�4-e
g (please print)
44 Signature Title •,'"e.1-y.7t7
/.
47 (over)
DOH-1555 (9/98)