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Grants, Jeffery K. NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records 4t, Name First Middle Last Sex Jeffery K.Grants Male Date of Death Age If Veteran of U.S.Armed Forces, 02/05/2021 63 Years War or Dates Place of Death Hospital,Institution or WCity,Town or Village Thurman Town Street Address 173 Don Potter Road,Thurman Town,New York 12810 p Manner of Death ©Natural Cause 0 Accident El Homicide Suicide ❑Undetermined ❑Pending W Circumstances Investigation W Medical Certifier Name Title p Anthony Petracca MD 1. Address ; 3 Irongate Center,Glens Falls,New York 12801 i' Death Certificate Filed District Number Register Number City,Town or Village Athol 5659 0002 ;�:? Burial Date Cemetery,Crematory or Facility Name q : q 02/09/2021 Pine View Crematory xl.❑Entombment Address 0 Cremation Queensbury Town,New York il ❑Donation 0— Removal Date Place Removed and/or and/or Held -- Hold Address N 0 Date Point of (!) ❑Transportation Shipment p by Common Carrier Destination r El Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number tm= 00037 it Name of Funeral Home Alexander Baker Funeral Home Address t. 3809 Main St,Warrensburg,New York 12885 `. Name of Funeral Firm Making Disposition or to Whom i-" Remains are Shipped,If Other than Above g Address I' W a. Permission is hereby granted to dispose of the human remains described above as indicated. Fl- Date Issued 02/09/2021 Registrar of Vital Statistics Susan StapCes((Cectronica1Ty Signed) ;" (signature/ District Number 5659 Place Athol, New York i;' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: H I W Date of Disposition Z 1lo i Zi Place of Disposition T '.'dressi-o c,..__ WCC number) CD (section) lot number) (grave g Name of Sexton or Person in Charge of Premiss � C S _ n 0 Z � (please prrint) L lil. Signature t4 Title 1. ` I( DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 014 52el Receipt s 1 Human remains of delivered on , 20 a i i Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#