Ladd Sr, James ft
NEW YORK STATE DEPARTMENT OF HEALTH ~ '�
Vital Records Section Burial - Transit Permit
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Name First Middle Last Sex
James Howard Ladd, Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
Nov. 15, 2015 78 yrs. War or Dates ' 54_I 97
Cry Place of Death Hospital, Institution or
City, Town or Village Fort Ann Street Address 196 Buttermilk Falls Rd.
a Manner of Death 0 Natural Cause 0 Accident 0 Homicide 0 Suicide ri Undetermined 17 Pending
LU Circumstances Investigation
Medical Certifier Name Title
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Address
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Death Certificate Filed District Number I Register Number
City, Town or Village Fort Ann 5754 I 15
❑Burial Date Cemetery or Crematory
['EntombmentNov. 16, 2015 Pi neView Crematnri um
Address
UCremation Queensbury, NPw York t2$n4
Date Place Removed
Z ri Removal and/or Held
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and/or Address
Hold
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O Date Point of .
Transportation Shipment
a by Common Destination
Carrier
<_ Q Disinterment
Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit issued to RMason Funeral Home O ai t ion Number
Name of Funeral Home
Address 18 George St. , PO. Box 277, Fort Ann, NY. 12827
Name of Funeral Firm Making Disposition or to Whom
14 Remains are Shipped, If Other than Above
;; Address
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Permission is hereby granted to dispose of the human re ns described above a in51 a d.
Date Issued 1 1 /1 6/1 5 Registrar of Vital Statistics ,�.
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District Number 5754 Place Town of Fort An , NY.
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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Date of Disposition II All/S' Place of Disposition � V� ,.yrniloCyv-..
2 (address)
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C (section) j"/ (lot number (grave number)
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• Name of Sexton or Person in Charg of Premises t,s d number).
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VIj Signature Title r1
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(over)
DOH-1555 (02/2004)