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Jones, Cole NEW YORK STATE DEPARTMENT OF HEALTH + # e5.Z Vital Records Section Burial - Transit Permit Name First Middle Last Sex Cole Matthew Jones Male Date of Death Age If Veteran of U.S. Armed Forces, November 6, 2017 1q War or Dates 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 ❑ Suicide ❑ Undetermined ❑ Pending ILICircumstances Investigation Medical Certifier Name Title Sereena Coombs, Dr. Address Death Certificate Filed District Number Register Number City, Town or Village Glens Falls --Seod 1 -5' ❑Burial Date Cemetery or Crematory November 13, 2017 Pine View Crematory ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z ❑ Removal I and/or Held a and/or Address Hold Date Point of ElTransportation Shipment by Common Destination a Carrier ElDisinterment Date Cemetery Address Date Cemetery Address ❑ Reinterment Permit Issued to Registration Number Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079 w Address 82 Broadway, Fort Edward NY 12828 Name of Funeral Firm Making Disposition or to Whom I- Remains are Shipped, If Other than Above Address Permission is he eby ranted to dispose of the human regains escribed bove as i dica d. Date Issued J$ egistrar of Vital Statistics ,j ay, )' (signature) District Numbe' -5( / Place . s.�x ,,a F- I certify that the remains of the decedent identified above were disposed of in accordan with this permit on: wDate of Disposition 11/13/2017 Place of Disposition Quaker Road Queensbury,NY 12804 f (address) CA EL (section) (lot number) (grave number) 17 6 aName of Sexton or Person in Charge of Pr mises (pl ase print) Signature viTitler6t7)19, (over) DOH-1555 (02/2004)