Eggleston, James -Ft 5 $
NEW YORK STATE DEPARTMENT OF HEALTH . . t
Vital Records Section Burial - Transit Permit
ffl Name First Middle Last Sex
James I Eggleston Male
Date of Death Age If Veteran of U.S. Armed Forces,
01/20/2012 11 years War or DateNo
#r•I Place of Death Hospital, Institution or
)ty, Towrge Wilton Street Addressorinth Mountain Road
G Manner of Death❑Natural Cause❑Accident El Homicide El Suicide ❑Undetermined ri❑Pending
In Circumstances Investigation
0.
in Medical Certifier Name Title
! Michael Sikirica Md
Address
50 Broad Street Waterford Ny 12188
Death Certificate Filed District Number Register Number
toetIty, TowrDOMattge Wilton 4569 3
:gi❑Burial Date Cemetery or Crematory
❑Entombment 01/30/2012 Pineview Cemetery
Address
: 0Cremation Town Of Queensbury
Date Place Removed
❑Removal and/or Held
oil!
and/orHold Address
O Date Point of
it Transportation Shipment
C by Common Destination
Carrier
Q Disinterment Date Cemetery Address
iiiiiii. : Reinterment Date Cemetery Address
ip Permit Issued to Registration Number
Name of Funeral Homaensmore Funeral H 00448
«_ Address .
iNi 7 Sherman Ave. Corinth, Ny
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
;; Address
2
uJ.
CL
` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued01/23/2012 Registrar of Vital Statistics /1/� '<l :`�
sign re)
District Numbqt69 Place Wilton
>;>.::; I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f' �l
w
Ili Date of Disposition 1 /3o I IL Place of Disposition s Ui,+-. air o r .�
Z. (address)
ilk
0
CC (section) got number) ,t (grave number)
Name of Sexton or Person in Charge of P mises t's4 "� St"`�4`
/ 1 (please print)
;: Signature
�" Title C.0 411 lr L Ji/1s
(over)
•
DOH-1555 (02/2004)