King, James t 4
NEW YORK STATE DEPARTMENT OF HEALTH :. till
Vital Records Section AP
111) Burial Transit Permit
Name First , p Middl ose h Lin
f K agt Sex
lale
Date of Death Age If Veteran,
{of U.S. Armed Forces,
08/07/2018 80 years
W .or Dates
w- Place of Death HotTiital, Institution or
Z City,XQ4 cXXXjIge Glens Falls Street Address Glens Falls Hospital
t Manner of Death Watural Cause n Accident ❑Homicide ❑Suicide ri❑Undetermined ❑Pending
iLi
0 Circumstances Investigation
W Medical Certifier Name Title
CI
AMdadrk A Quaresima M D
161rearey Road Queensbury, Ny 12804
Death Certificate Filed District Number Register Number
City,)( G 4 c e Glens Falls 5601 w -.
375 .
El Burial Date Cemetery or Crematory
08/09/2018 Pine View Cematory
❑Entombment Address
remation Queensbury, Ny
Date Place Removed
Z Removal and/or Held
2❑and/or Address
t Hold
Date Point of
11' jr7Transportation Shipment
a by Common Destination
Carrier
Disinterment Date ' Cemetery Address
-L i Reinterment Date Cemetery Address
Permit Issued to ReAistration Number
Name of Funeral Home Regan & Denny Funeral Home 01444
Address
94 Saratoga Ave. South Glens Falls, N Y
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
W.
,a Address
I
Ili
et Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/08/2018 Registrar of Vital Statistics W
Ci1/4AlrYNa
(si nature)
District Number5601 Place Glens Falls j IV>.,
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILE Date of Disposition $��a lift Place of Disposition e.g.. � ,,.,,,.,
(address)
ill
IC (section) (lot nu ber) (grave number)
in Name of Sexton or Person in Charge of Premises ,{o Sri.�i
(please pnn J!
Signature Title 1IZE+''Mi7J
(over)
DOH-1555 (02/2004)