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Jones, Ethan ,, 55/ NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit ▪ Name First Middle Last Sex Ethan J Jones Male Date of Death Age If Veteran of U.S. Armed Forces, July 24, 2015 24 War or Dates Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death Natural Cause Accident Homicide Suicide x Undetermined Pending Circumstances Investigation gi h Il Mhfilphy,Cow Title ::. Address • 52 Haviland Ave, Glens Falls,NY 12801 ;xc Death Certificate Filed District Number aD()) Re ste�r umber • City, Town or Village 07/27/2015 � ��`` ❑Burial Date Cemetery or Crematory July 30, 2015 Pine View Crematorium ❑Entombment Address ❑x Cremation 21 Quaker Road, Queensbury, NY 12804 Date Place Removed Z Removal and/or Held and/or Address F Hold V) O Date Point of NI I Transportation Shipment p by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address :,ii' Permit Issued to Registration Number • Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address 407 Bay Road, Queensbury, NY 12804 i Name of Funeral Firm Making Disposition or to Whom ▪ Remains are Shipped, If Other than Above Address ' . Permission is hereby granted to dispose of the human remains c ib d a ve ndicated. Date Issued © 47/20/5— Registrar of Vital Statistics J5� (signature) District Number ,SZCV Place 7 // ,Ny I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Q Z w Date of Disposition r7-alb-fc Place of Disposition Pine t/,'ec./. Cr,»,4.{af,'Ww. M (address) W Cl) Ce (se (lot number) (grave number) Z• Name of Sexton or Person in Charge of Premises ( l'ry,o-�,,y rt-vn.elt W g ��/, ay (please print)l Signature 4,1..„.,,JJ��J Title C reinAlbesi ci4 (over) DOH-1555(02/2004)