Flansburg, Jason NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section f z Burial - Transit rermit
Name First Middle Last Sex
Jason W. Flansburg Male
.. Date of Death Age If Veteran of U.S.Armed Forces,
' August 8, 2014 81 War or Dates Yes 1956-1960
IE- Place of Death Hospital, Institution
Z City,Town or Village City of Albany or Street Address Albany Medical Center
Manner of Death Natural ❑ Undetermined ❑ Pending
® Cause ❑ Accident ❑ Homicide ❑ Suicide Circumstances Investigation
Medical Certifier Name Title
0 Edit Masaba MD
Address
35 Gilbert Street, Cambridge, NY 12816
Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 1488
Date Cemetery or Crematory
❑ Burial August 8, 2014 Pineview Cemetery
❑ Entombment Address
LE Cremation Queensbury, NY
Date Place Removed
Z Removal and/or Held
0 ❑ and/or Address
— Hold
CO
Date Point of
0. Transportation Shipment
CO ❑ By Common Destination
C▪i Carrier
❑ Disinterment
Date Cemetery Address
Date CemeteryAddress A
❑ Reinterment
F=` Permit Issued To Registration Number
Name of Funeral Home Densmore Funeral Home 00448
Address
7 Sherman Ave., Corinth, NY 12822
Name of Funeral Firm Making Disposition or to Whom
F Remains are Shipped, If Other than Above
FAddress
W /13-' Permission is hereby granted to dispose of the human remains described abo asYindicated. / id
Date August 8, 2014 Registrar of Vital Statistics ` ' `l� l
Issued (signature)
District Number 101 Place City of Albany, NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
li Date of Disposition 'ill lig Place of Disposition t�rilli-,/ 6n "—
I (address)
w
U)
re (section) (lot number)0 C (grave number)
o' /L7
Name of Sexton or Person in Charge of Premises
IL
/� (please print)
Signature II-S Title C vollTvfL
(over)
DOH-1555 (02/2004)