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Wixson, John • NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital.Records Name First Middle Last Sex John Wixson Male Date of Death Age If Veteran of U.S.Armed Forces, 01/17/2021 51 Years War or Dates .,.. Place of Death Hospital,Institution or WCity,Town or Village Queensbury Town Street Address 22 Bay Road Apt#2,Queensbury Town,New York 12804 p Manner of Death ❑Natural Cause Accident 0 Homicide 0 Suicide El Undetermined ©Pending a Circumstances Investigation LU Medical Certifier Name Title Connie Goedert Coroner Address 1400 St Route 9,Lake George Town,New York 12845 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 22 , ©Burial Date Cemetery,Crematory or Facility Name 01/22/2021 Pine View Cemetery 0 Entombment Address 0 Cremation Queensbury Town,Warren,New York ❑Donation OZ El Removal Date Place Removed and/or and/or Held ~ Hold Address i 0 d Date Point of Cl) Li Transportation a by Common Shipment Carrier Destination El Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom .— Remains are Shipped,If Other than Above S Address CC W Q. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/21/2021 Registrar of Vital Statistics Caroline.-CiCclegardeBarber(Efectronica1TySigned) (signature) District Number 5657 Place Queensbury, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: H 6 Date of Disposition 1 /22/2021 Place of Disposition 21 Quaker Rd _ Queensbury, nY 12804 (address) W Horicon 43 C 1 m cc (section) (lot number) (grave number) 8 Name of Sexton erson in Charge of Premises Connie Goedert Z (please print) W Signatures —2 e�� Title Superintendent DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 012837 Receipt Human remains off,.. '!� t:. •• f':. ''+ delivered on. -•• , 20 v y fi� Pine View emeery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# ! s __ Wixson NAME John Wixson Age: 51 qi � Lot Owner: JohnWixson Lot# Horicon f..4 6 C Grave# 1 Case: Concrete Died: 1 /1 7/2 0 21 Interred:/2 2/2 0 21 Funeral Home: Carleton FH Cemetery: Pine View