Langdon, Jason 0 Sb 7,
NEW YORK STATE DEPARTMENT OF HEALTH
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Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Jason F Langdon Male
Date of Death Age If Veteran of U.S. Armed Forces,
07/09/2018 43 years War or Dates
1 Place of Death Hospital, Institution or
W % 'own or ViititMea Halfmoon Street Address Dirt Road Off Button Road, Halfmoon, N Y
ilk Manner of Death❑Natural Cause D Accident ❑Homicide ❑Suicide ❑Undetermined El Pending
Lid Circumstances Investigation
u Medical Certifier Name Title
Michael Sikirica M D
Address
50 Broad St., Waterford, N Y 12188
Death Certificate Filed District Number Register Number
xown or VIEW Halfmoon 4559 27
❑Burial Date Cemetery or Crematory
07/11/2018 Pine View Cemetery
['Entombment Address
[]Cremation Queensbury, New York
Date Place Removed
Removal and/or Held
9❑and/or
� Address
i
Hold
0 Date Point of
N ❑Transportation _Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to - Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road, Queensbury, Ny 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
In
IL
Permission is hereby granted to dispose of the human s describe abov s indicated.
Date Issued 07/11/2018 Registrar of Vital Statisti s
(signature
District Number 4559 Place Halfmoon
! I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 7f 1z jig Place of Disposition 0.... Ler....
2 (address)
Ul
U)
CC (section) AL
umber), (grave number)
v'.' Name of Sexton or Person in Charge f Premisesy J\
2
se print)
Signature Title
(over)
DOH-1555 (02/2004)