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Gendron, Jean NEW YORK STATE DEPARTMENT OF HEALTH $ C6-3 Vital Records Section Burial - Transit Permit Name First Middle Last Sex Jean Paul Gendron Male Date of Death Age If Veteran of U.S. Armed Forces, July 12,2017 83 War or Dates F Place of Death Hospital, Institution or Z, City, Town or Village Johnsburg Street Address 394 Goodman Road Ill a Manner of Death I XI Natural Cause Accident Homicide Suicide Undetermined Pending .W Circumstances Investigation ©' Medical Certifier Name Title William A. Tedesco Dr. Address Three Iron Gate Center,Glens Falls,NY 12801 Death Certificate Filed District Number l Register f,Vumber City, Town or Village Johnsburg 5 o v I ( ❑Burial Date Cemetery or Crematory July 18,2017 Pine View Crematory 0 Entombment Address ❑x Cremation 21 Quaker Rd., Queensbury, NY 12804 Date Place Removed Z I I Removal , and/or Held and/or Address H Hold Cl) 0 Date Point of co Transportation Shipment a by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to 1 Registration Number • Name of Funeral Home Alexander-Baker Funeral Home j 00037 Address 3809 Main Street, Warrensburg,NY 12885 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above S Address ALI "' Permission is hereby granted to dispose of the human ains described above as indicated. Date Issued ri — 1p-( ) Registrar of Vital Statistics (signature) District Number (Q Place Q U.1� s___)(4\nJ uS n Wi h I certify that the remains of the decedent identified above were disposed of in accords ce t this permit on: Z W Date of Disposition /ZO/// Place of Disposition Pi-ha u i e� Ga d W (address U) O (section) (lot number) (grave number) p Name of Sexton or P n � Charge of Premises L.L. ,e, i ,i �4�n 4_c�+-6e Z (please print) W Signature - Title C/"Q- �-44,.-- (over) DOH-1555 (02/2004)