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Mattison, Earl 1 / tl o NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Earl J. Mattison Male Date of Death Age If Veteran of U.S. Armed Forces, • June 24, 2017 80 yrs. War or Dates n/a Place of Death Hospital, Institution or W City, Town or Village Fort Ann Street Address 1 528 Mattison Rd. fl Manner of Death©Natural Cause Accident Homicide 0 Suicide Undetermined Pending 1a Circumstances Investigation tu Medical Certifier Name Title O John Stoutenburg MD Address 102 Park St. , Glens Falls, NY. 12801 Death Certificate Filed District Number Register Number City, Town or Village Fort Ann 5754 7 El Burial Date Cemetery or Crematory ['Entombment Address 27 , 2017 PineView Crematorium Address ®Cremation Quaker Rd. , Queensbury, NY. 12804 Date Place Removed Removal and/or Held H and/or Address Cif) Hold O Date Point of rL 0 Transportation Shipment ct by Common Destination Carrier ❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Mason Funeral Home 0111 7 Address 18 George St. PO Box 277 Fort Ann, NY_ 12827 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above • Address CC f fl" Permission is hereby granted to dispose of the human rem ins described a ve as indicated. Aii Date Issued June 26, 2(Fihlistrar of Vital Statistics � tt- (signature) District Number 5-75-r Place Town of Fort Ann, NY. "" I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z ilk Date of Disposition 6/21j f Place of Disposition fiat qpi... 4,-1.A._ (address) Lu CC (section) (lot number) r (grave number) i• Name of Sexton or Person in Charge of Premises L nr•s1 d"'tt0l zr a/ 1 ( lease print) Signature l -r Title riltriViftrall (over) DOH-1555 (02/2004)