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Mattison, Jeffery 4 ')s2_ NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit , Name First Middle Last Sex Jeffery Scott Mattison Male Date of Death Age If Veteran of U.S. Armed Forces, 10/05/2017 51 Years War or Dates j- Place of Death Hospital, Institution or WCity, Town or Village Glens Falls Street Address Glens Falls Hospital p Manner of Death©Natural Cause ❑Accident ❑Homicide El Suicide ❑Undetermined El❑Pending Circumstances Investigation W Medical Certifier Name Title ©' Noelle Stevens MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number _' City, Town or Village Glens Falls 5601 526 ['Burial Date Cemetery or Crematory 10/10/2017 Pine View Crematorium ['Entombment Address ®Cremation Queensbury Town, New York ZDate Place Removed t ❑Removal and/or Held and/or Address Hold 0 Date Point of u)❑Transportation Shipment O by Common Destination ',, Carrier ❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Stpo Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom t Remains are Shipped, If Other than Above • Address re W' 0. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/10/2017 Registrar of Vital Statistics t6ert)1 Curtis TEfectronicalySigned (signature) District Number 5601 Place Glens Falls, New York i,, I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z n LLI: Date of Disposition ID IIZ Ii) Place of Disposition fl u,.,, ..., or'.,. (address) CO L1; (section) (lit number) (grave number) pName of Sexton or Person in Charge of Premises /r/ S Z (pl ase kint) lU Signature . Title 1 Of 1067)1_ (over) DOH-1555 (02/2004)