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Ward, Gary A # c NEW YORK STATE DEPARTMENT OF HEALTH , *a ,,*n Vital Records Section Burial - Transit Permit Name First Middle Last Sex Male Date of Death ry Age A' If Veteran of U.S. Armed Forces, July 07, 2021 64 yrs. War or Dates n/a 1 Place of Death Hospital, Institution or WCity, Town or Village South Glens Falls Street Address 129 Saratoga Ave. its, Manner of Death©Natural Cause ❑Accident IIIHomicide ['Suicide ❑Undetermined ri❑Pending W Circumstances Investigation ui Medical Certifier Name Title 0 naniellP Jourdan Coroner Address 4205 Rte. 50, Saratoga Springs,NY. 12866 Death Certificate Filed District Number RegisNI mber City, Town or Village South rl Pnc Fa 1 1 c 4524 j ❑Burial Date � Cemetery or Crematory / _ -��5 Pineview Crematorium ❑Entombment Address Cremation Quaker Rd_ , Queensb r , NY_ 12804 Date Place Removed ❑Removal and/or Held and/or Address i= Hold I O Date Point of ti❑Transportation Shipment _ t by Common Destination Carrier El Disinterment Date ' Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Mason Funeral Home 01 1 1 7 Address 18 George St. , Fort Ann, NY_ 12R27 Name of Funeral Firm Making Disposition or to Whom 1.4 Remains are Shipped, If Other than Above • Address t lU ` Permission is hereby ranted to dispose of the hum remains described above as indicated. Date Issued 7 e7 �/ Registrar of Vital Statistics (signet `. District Number 4524 Place Village o S uth Glens Falls, NY. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: iii Date of Disposition 7 i it(1.1 Place of Disposition .,, lL ak (address) ILIA U) cc (section) (lot number) (grave number) • Name of Sexton or Perso in Charge of P emises ` r 2, (pleas print) 41 • l Title (4144 19 : Signature (over) DOH-1555 (02/2004) r I PA I. Public Health Law Sec. 4145(2b) 41,9 2 3 Receipt - Human remains of - / "•`-' delivered on ' , 20 , 1 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#