Jordon, Arthur NEW YORK STATE DEPARTMENT OF HEALTH. . .N ZZ
Vital Records Section Burial - Transit Permit
gi;i-i.i Name First Middle Last Sex
Arthur Jordon Male
✓ ;!al Date of Death Age If Veteran of U.S. Armed Forces,
4/1 7/1 3 83 War or Dates No
Place of Death Hospital, Institution or
City, Town or Village Argyle Street Address 72 Todd Road, Argyle, N
Ult
Manner of Death®Natural Cause 0 Accident D Homicide D Suicide D Undetermined D Pending
Circumstances Investigation
til
ut Medical Certifier Name Title
William Parker MD
Address
Hudson Headwaters, East Street, Fort Edward, NY 12828
Death Certificate Filed DistricAi ber Register Number ,R
City, Town or Village Argyle ,.) ((D
V
iliiiiiii❑Burial Date Cemetery or Crematory
4/18/13 Pine View Crematory
°y:: DEntombment Address
;;;:::Cremation Queensbury, NY
Date Place Removed
Removal and/or Held
404 'I and/or Address
hh. Hold
O
O.
Date Point of
14 Q TransportationVA Shipment
0 by Common Destination
Carrier
0 Disinterment Date Cemetery Address
:?: Q Reinterment Date • Cemetery Address
li Permit Issued to Registration Number
Name of Funeral Home M.B. Khmer Funeral Home 01 077
Address
123 Main St. Argyle, NY 12809
iN Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address •
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''' Permission is hereby granted to dispose of the human emains descri ed above as indicated.
Mi Date Issued 4/1 8/1 3 Registrar of Vital Statistics itY\CK(U-A.,---
(signature)
District Number Place argyle, NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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Date of Disposition (4-ir-3 Place of Disposition —? L i & rsi,..,
(address)
44
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises r� Jr?not{
(grave
z (p ase print)
Signature L : Title e- .Nieijvit.
(over)
DOH-1555 (02/2004)