Epting, III Paul NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit�liermit
Vital Records Section
Name First Middle Last Sex
Paul Epting, III Male
Date of Death ' Age If Veteran of U.S.Armed Forces,
�, - April 1, 2011 57 War or Dates
Z Place of Death Hospital, Institution or
W City,Town,or Village Whitehall Street Address Residence
G Manner of Death E Natural Cause 0 Accident 0 Homicide 0Suicide 0 Undetermined 0 Pending
W Circumstances Investigation
0 Medical Certifier Name Title
W John Stoutenberg MD
0 Address
102 Park Street, Glens Falls, New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Whitehall .�"`7"44
❑Burial Date Cemetery or Crematory
April 5, 2011 Pineview Crematorium
❑Entombment Address
0 Cremation Queensbury, New York Queensbury, NY 12804
Date Place Removed
0 0 Removal and/or Held
and/or Address
' Hold
0 i
Date Point of
Q0 Transportation Shipment
d by Common Destination
Carrier
Date Cemetery Address
a 0 Disinterment
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00897
Address
46 Williams Street, Whitehall, New York 12887
~ Name of Funeral Firm Making Disposition or to Whom
ce Remains are Shipped, If Other than Above
W Address
a.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued /06 0/ Registrar of Vital Statistics r �. t_
(sign re)
District Number S74 4. Place Whitehall,New York
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
WDate of Disposition 04/05/2011 Place of Disposition Pineview Crematorium
2 (address)
al
In
section
0 (section) A (lot number) (grave number)
a Name of Sexton or Person in Charge of Pre ses 0 r,sioAte t?nivit
Ill (please print)
Signature /14719.-, Title IPE04 1d--
(over)
DOH-1555 (02/2004)