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West, James Elwyn Ili OJ 1j 1 NEW YORK STATE DEPARTMENT OF HEALTH St Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex James Elwyn West Male Date of Death Age If Veteran of U.S.Armed Forces, 12/02/2021 81 Years War or Dates Place of Death Hospital,Institution or W City,Town or Village Glens Falls Street Address Glens Falls Hospital p Manner of Death © Natural Cause Accident ❑Homicide El Suicide Undetermined Pending W Circumstances Investigation W• Medical Certifier Name Title G Gamal Khalifa MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 565 12 Burial Date Cemetery,Crematory or Facility Name 12/04/2021 Pine View Crematory ❑Entombment Address X❑Cremation Queensbury Town,New York ❑Donation g ❑Removal Date Place Removed and/or and/or Held ~ f Hold Address 0 a Date Point of u) ❑Transportation Shipment p by Common 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 F— Remains are Shipped,If Other than Above 2 Address W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/03/2021 Registrar of Vital Statistics Rpdert Andrew 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: z `✓t or--. W Date of Disposition PA�Z� Place of Disposition tac. �.. (address) W N (section) (lot number) (grave number) l�r.s � SName of Sexton or Person in Charge of mises Z (p/eas print) ft W �3 Title ( � Signature DOH-1555(07/18)p 1 of 2 f r R., ff..,' "Ti 0 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#