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Villmore, Jon L. NEW YORK STATE DEPARTMENT OF HEALH r� Vital Records Section Burial - Transit Permit Name First Middle Last Sex Jon Paul Villmore Male Date of Death Age If Veteran of U.S. Armed Forces, November 11, 2016 54 War or Dates I Place of Death Hospital, Institution or W City, Town or Village Queensbury Street Address 12 Windsong Drive, Queensbury, NY 128C W Manner of Death a Natural Cause 0 Accident 0 Homicide 0 Suicide 0Undetermined ri Pending Circumstances Investigation W Medical Certifier Name Title in clr\OL 4014 OP o'o ow/L.- Address tei 2 '3 s {t)"� L,� ( vial r ►�tnITC tr of) Death ificate Fil District Number Register Number Ci Town o Villag Q -*.� _ A'---) / c 1 ❑Burial Date Cemetery or Crematory November 17, 2(- Pine View Cemetery ❑Entombment Address ©Cremation Quaker Rd. Queensbury,NY 12804 Date Place Removed Removal and/or Held and/or Address E Hold Pine View Cemetery Date Point of p11 Transportation Shipment co by Common Destination CI Carrier 0 Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home, Inc. 00281 Address Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839 Name of Funeral Firm Making Disposition or to Whom I— Remains are Shipped, If Other than Above 2 Address W' a' Permission is hereb granted to dispose of the huma remains described ove as indicated. Date Issued 11, 1 (col(n Registrar of Vital Statistics7Q /Uc_,_� (:::� (��? (signature) District Numt�(�� l Place . . I certify that the remains of the decedent identified above were disposed o ' accordance ith this permit on: ill Date of Disposition 11/17/2016 Place of Disposition Quaker Rd. Queensbury, 804 E (address) W` CO it (section) (lot number) (grave number) Q' Name of Sexton or Person in Charge of remises A( ,- Si milt Z, (pl ase print) W Signature e'C Title (Rcrn+tiD&�. (over) DOH-1555 (02/2004)