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Pearson, John Emil NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex John Emil Pearson Male Date of Death Age If Veteran of U.S.Armed Forces, 03/17/2021 79 Years War or Dates 1959-1975 F Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital pManner of Death ©Natural Cause p Accident 0 Homicide 0 Suicide ❑Undetermined Ei Pending UCircumstances Investigation ILI 0 Medical Certifier Name Title Mathew Varughese DO Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 150 ❑Burial Date Cemetery,Crematory or Facility Name 03/18/2021 Pine View Crematorium 0 Entombment Address X❑Cremation Queensbury Town,New York 0 Donation ZEI Removal Date Place Removed and/or a—) and/or Held F- Hold Address 0 d Date Point of N 1-1 Transportation CI by Common Shipment Carrier Destination riDisinterment 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 f-. Remains are Shipped,If Other than Above a Address CC W a' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/18/2021 Registrar of Vital Statistics Rp6ertAnclrew Curtis(ECectronicalTy Signed) (signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition 3 j ZZ i 7i Place of Disposition �L �,�(� (ad ress) W N CC (section) (lot auger) (grave number) gName of Sexton or Person in Charge of Premises 4,, L .. i 4IT z e /please print/W Signature ....aTitle fell npf- DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) '� 4655 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#