Eggleston Sr, James .. It1(.0
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
James E. Eggleston,Sr. Male
: Date of Death Age If Veteran of U.S. Armed Forces,
g: December 5, 2014 68 War or Dates Vietnam
▪ Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Pi Paul Bachman
Address
3767 Main Street,Warrensburg,NY 12885
Death Certificate Filed District Number Register Number
_ _▪ City, Town or Village Glens Falls 5601 5 (I_may
❑Burial Date Cemetery or Crematory
December 10, 2014 Pine View Crematorium
❑Entombment Address
❑X Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ I I Removal and/or Held
and/or Address
t Hold
N
O Date Point of
O. Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
• Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
k':' Remains are Shipped, If Other than Above
Address
;1' : Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued Li) q / 19 Registrar of Vital Statistics 'i,/3 c L.&7-.sZ kik)..� d""'y
(signature)
'i? District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance withit this permit on:
W Date of Disposition IL(101►1 Place of Disposition i,., .ew t, •i.....
W (address)
CO
O (section) (lot number) (grave number)
Q• Name of Sexton or Person in Charge of Premises ttrisi 5e"
Z (please print)
W Signature At,,,, Title CAE woe
(over)
DOH-1555(02/2004)