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Jacobson, Alfred t t NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Alfred W. Jacobson Male Date of Death Age If Veteran of U.S. Armed Forces, November 11,2016 67 War or Dates 8 Place of Death Hospital, Institution or , City, Town or Village Glens Falls Street Address Glens Falls Hospital c3 Manner of Death g Natural Cause Accident Homicide Suicide Undetermined Pending Circumstances Investigation EL Medical Certifier Name Title P James North Address 100 Broad Street,Glens Falls,NY 12801 Death Certificate Filed District Number Re ister Number City, Town or Village Glens Falls 5601 141 ❑Burial Date Cemetery or Crematory Pine View Crematory El Entombment Address ©Cremation 21 Quaker Rd., Queensbury, NY 12804 Date Place Removed Z Removal and/or Held and/or Address H Hold Cl) 0 Date Point of NTransportation Shipment p by Common Destination Carrier Disinterment Date Cemetery Address pi Reinterment Date Cemetery Address y' Permit Issued to Registration Number a� Name of Funeral Home Alexander-Baker Funeral Home 00037 Address 3809 Main Street,Warrensburg,NY 12885 Name of Funeral Firm Making Disposition or to Whom l-.a Remains are Shipped, If Other than Above S Address te a. Permission is herebygranted to dispose of the human rains de cribed above as nn irate . �' Date Issued J I ]�, ��(� Registrar of Vital Statistics (signature) District Number .67 i Place " (,._4 e�0 I certify that the remains of the decedent identified above were disposed of in accords a with this permit on: w Date of Disposition tiff 7 J/[o Place of Disposition P, , v, 'J C,,..e,a 4... W (address) Cl) IX (section) (lot number) J (grave number) p Name of Sexton or Person in Charge of Premises gcs,. !�j - ,— 1�Q r Z / (please print) W Signature Zf."--- L,/ 9,‘ Title �'8, ' l/ (over) DOH-1555 (02/2004)