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Streicher, Sheldon Ross Town of Queensbury s Certification of Cremation � � Pine View Cemetery and Crematory This certifies that the remains of: John M. South were cremated on February 24 20 21 at the Pine View (Month) (Day) Crematorium, Queensbury,New York, and these are the cremated remains of said body. Date of Death February , 20 20 21 Age 48 (Month) (Day) Funeral Home Regan Denny Stafford Registered No. 209 7uthori d Signatu I 1ZZ NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records P Name First Middle Last Sex Sheldon Ross Streicher Male Date of Death Age If Veteran of U.S.Armed Forces, k- 01/28/2021 38 Years War or Dates j Place of Death Hospital,Institution or ZCity,Town or Village Fort Ann Town Street Address 149 State Route, Fort Ann Town,New York 12827 p Manner of Death El Natural Cause El AccidentHomicide ©Suicide El UndeterminedPending 0 Circumstances Investigation LUU Medical Certifier Name Title 0 Robert Lemieux Coroner Address 415 Lower Main Street,Hudson Falls Village,New York 12839 Death Certificate Filed District Number Register Number City,Town or Village Fort Ann 5754 1 ElBurial Date Cemetery,Crematory or Facility Name 02/03/2021 Pine View Crematory ❑Entombment Address ElCremation Queensbury Town,New York ❑Donation OZ Removal Date Place Removed and/or and/or Held F- Hold Address W 0 EL Date Point of N �Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079 Address 82 Broadway,Fort Edward,New York 12828 Name of Funeral Firm Making Disposition or to Whom 1-. Remains are Shipped,If Other than Above a Address is W n' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/01/2021 Registrar of Vital Statistics Barbara 9 Winched(E(ectronicafIySigned) (signature) District Number 5754 Place Fort Ann, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: IH W Date of Disposition 213171 Place of Disposition (a dress) W N CC (section) lot number) (grave number) Name of Sexton or Person in Charge of P emises G i1 & < J�►a gbh Z (pleas print) fW Signature Title G '` � DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 1 -,! 1 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# SOUTH NAME Age: John South 48 Lot Owner: Karen South Lot# S & I Lot 144 Sec 2 Grave# 3 Case: Urn Interred:3/5/2 0 21 Died: 2/2 0/2 0 21 Funeral Home: Regan Denny Stafford Cemetery: pine View