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Jansson, William NEW YORK STATE DEPARTMENT OF HEALTH i 3 1 3l-e Vital Records Section Burial - Transit Permit Name First Middle Last Sex William R. Jansson Male Date of Death Age If Veteran of U.S. Armed Forces, April 17, 2017 84 War or Dates Place of Death Hospital, Institution or City, Town or Village Fort Edward Street Address 325 Broadway Manner of Death X❑Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined 1-1 1---I Pending CircumstancesInvestigation ill Medical Certifier Name Title Christopher Messitt, Dr. Address 135 North Road Gansevoort, NY 12831 Death Certificate Filed District Number 5r165 Registel Number City, Town or Village Fort Edward ❑Burial Date Cemetery or Crematory April 20, 2017 Pine View Crematory ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 W. Date Place Removed ❑ Removal and/or Held and/or Address E Hold OW Date Point of ,..❑Transportation Shipment by Common Destination Carrier Date Cemetery Address ❑ Disinterment Date Cemetery Address ❑ Reinterment Permit Issued to Registration Number Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079 Address 82 Broadway, Fort Edward NY 12828 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address Permission is hereb granted to dispose of the human re ins des1�cri%cl as ove indicated. ::: :: 10 ber _el 66 Place CULd I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: in Date of Disposition 04/20/2017 Place of Disposition Quaker Road Queensbury,NY 12804 2 (address) ( (grave number) �' Name of Sexton or Person in Charg of Premises (section) trlot, number)S/, l ff' (pl se print) Signature Title NHIV1 (L, (over) DOH-1555 (02/2004)