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Jolley, LeRoy NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex LeRoy Stanton Jolley Male a Date of Death Age If Veteran of U.S. Armed Forces, _ 12/19/2017 79 Years War or Dates ift Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death©Natural Cause ElAccident ❑Homicide ❑Suicide ❑Undetermined El❑Pending kliCircumstances Investigation w Medical Certifier Name Title Farhana Kemal MD P Address 100 Park St,Glens Falls,New York 12801 ', Death Certificate Filed District Number Register Number City, Town or Village Glens Falls 5601 658 ❑Burial Date Cemetery or Crematory 12/21/2017 Pine View Crematorium 1❑EntombmentI NA Address ®Cremation Queensbury Town, New York Date Place Removed X❑Removal and/or Held and/or Address Hold co Q Date Point of co❑Transportation Shipment 0 by Common Destination tti Carrier Disinterment Date Cemetery Address 4. 0 ❑Reinterment Date Cemetery Address ,'' Permit Issued to Registration Number i ; Name of Funeral Home Carleton Funeral Home Inc 00281 t,; Address r 68 Main Stpo Box 67,Hudson Falls,New York 12839 E Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address al • Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/21/2017 Registrar of Vital Statistics &6ertACurtis rElectronicaaySigned I'li£ (signature) :: District Number 5601 Place Glens Falls, New York WI certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition j 2, 2.9!7 Place of Disposition ?i)-1 Q k)l) (,/'P 4.ic"f (address) (section) (l number) (grave number) AName of Sexton Pro in Charge of Premises JL„,_ I 64, 4A-6,11- (please print) Signature `� Title L �g m a a (over) DOH-1555 (02/2004)