VanGuilder, James NEW YORK STATE DEPARTMENT OF HEALTH. u. .-s tf S 1 C
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
James E. VanGuilder Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 6, 2012 78 War or Dates
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:'o Place of Death Hospital, Institution or
{ City, Town or Village Glens Falls Street Address Glens Falls Hospital
e! Manner of Death 7 Natural Cause I 1 Accident —Homicide Suicide Undetermined Pending
Iv — Circumstances Investigation
Medical Certifier Name FRA14 moil 9er /1 P. 4�J
tle
]. ii' Address Ll-2i Ey e6A6 oft -k561.,e_y , iJ`i_ 12 8O4
:.:.' Death Certificate Filed District Number Register//N ber
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City, Town or Village Glens Falls 5601 7 �
❑Burial Date Cemetery or Crematory
October 9, 2012 Pine View Crematorium
❑Entombment Address
0 Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZO n Removal and/or Held
and/or Address
H Hold
co
Q Date Point of
N n Transportation Shipment
a by Common Destination
Carrier
n Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
.,;:; Permit Issued to Registration Number
flpaa Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
_':' 407 Bay Road, Queensbury,NY 12804
.a;x: Name of Funeral Firm Making Disposition or to Whom
i ? Remains are Shipped, If Other than Above
g Address
re
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ai
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 6 O 0 I l z Registrar of Vital Statistics le Ci_AdyL- ,
(signature)
. District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition to/1 la, Place of Disposition Zgt/ut. a„.atf iv
2 (addre s)
W
W
0' (section) lf/ (lot number) .- (grave number)
QName of Sexton or Person in Charg of Premises Chr�i 31MN1+
Z it (please print)
iss
Signature G Title Cr w ATat
(over)
DOH-1555(02/2004)