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Hallock, Harold 1 -Pt35) NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit - Name First Middle Last Sex Harold A.Ha[lock Male 'P Date of Death Age If Veteran of U.S.Armed Forces, Nctt 04/30/2018 82 Years War or Dates Place of Death Hospital, Institution or 4 City, Town or Village Ticonderoga Town Street Address Heritage Commons Residential Health Care Cr Manner of Death©Natural Cause 0 Accident 0 Homicide El Suicide 0 Undetermined El Pending 3 `re Circumstances Investigation rir Medical Certifier Name Title Glen Chapman MD Address 1019 Wicker St,Ticonderoga Town,New York 12883 Death Certificate Filed District Number Register Number City, Town or Village Ticonderoga 1564 19 ❑Burial Date Cemetery or Crematory 05/04/2018 Pine View Crematory El Entombment Address kl®Cremation Queensbury Town, New York Date Place Removed PR Removal and/or Held rua and/or Address Hold Date Point of Transportation Shipment by Common Destination Carrier s Date Cemetery Address Q Disinterment wzi Reinterment Date Cemetery Address 'la Permit Issued to Registration Number Name of Funeral Home Jillson Funeral Home Inc 00885 rt Address im 46 Williams Street,Whitehall Village,New York 12887 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above 4-77 Address Tr- Permission is hereby granted to dispose of the human remains described above as indicated. 41 Date Issued 05/02/2018 Registrar of Vital Statistics Tonya MThompson(E1ectronica fry Signed) (signature) District Number 1564 Place Ticonderoga, New York ' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition S hilt iilt Place of Disposition 1�K L,w (R-I- t-=' (address) (section) (lot mber) (grave number) Name of Sexton or Person in Charge of Premises i 5 AP (please int) Signature Title (441 NUR (over) DOH-1555 (02/2004)