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Pouliot, James Joseph NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Vital Records .,:�,,;� Burial - Transit Permit Name First Middle Last Sex James Joseph Pouliot Male Date of Death Age If Veteran of U.S.Armed Forces, 08/25/2021 73 Years War or Dates Army i_ Place of Death Hospital,Institution or ILJ Z City,Town or Village Glens Falls Street Address Glens Falls Hospital p Manner of Death ©Natural Cause Ei Accident El Homicide ❑Suicide 0 Undetermined, Pending W Circumstances Investigation 0 Medical Certifier Name Title Matthew Loftus PA Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 364 Burial Date Cemetery,Crematory or Facility Name 08/27/2021 Pine View Crematory ❑Entombment Address 0 Cremation Queensbury,New York ElDonation 0 ❑Removal Date Place Removed i= and/or and/or Held N Hold Address 0 Cl. Date Point of (/) 11 Transportation 0 by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan Denny Stafford Funeral Home 01443 Address 53 Quaker Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped,If Other than Above 2 Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 08/27/2021 Registrar of Vital Statistics qZ96ertAnerew Curtis(E(ectronica1Ty 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: ZZ IJJ Date of Disposition V-2 .-2pZ/ Place of Disposition Pdh p. J 6r-e- e-10 2 (address, W N cc (section) (lot number) (grave number) Name of Sexton or Pers in arge of Premises -L., 1 t Cvn 4/.dt 4 Z (please print) W Signature Title C-P-e.✓n �f/ �JDea7 �s DOH-1555(07/18) 1 of 2 / / #asuaaq io•2aj sJoaaa.uia ie.zaund im131.130 1iuuad'Tunq uo puma auzoq imaunj alp uuuasaida>i X.ta;ama3 ma►A OUtd OZ ` uo palantlap 3o sup uzai urtunf lcIpaag (gZ)Stit 'DOS IPMaH ailand