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Holster, James Jay ,ti /0°3 NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex James Jay Holser Male Date of Death Age If Veteran of U.S.Armed Forces, 11/20/2021 58 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital WManner of Death ©Natural Cause Accident 1=1 Homicide 1=1 Suicide 1=1 Undetermined El Pending Circumstances Investigation ILI Medical Certifier Name Title David Cunningham MD Address 3 Irongate Center,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 540 ElBurial Date Cemetery,Crematory or Facility Name 11/26/2021 Pine View Crematory Entombment Address Cremation Queensbury Town,New York ❑Donation 0 Removal Date Place Removed and/or and/or Held to Hold Address 0 a Date Point of to ❑Transportation by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Maynard D Baker Funeral Home 01130 Address 11 Lafayette St,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom F— Remains are Shipped,If Other than Above 2 Address CC W n' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/26/2021 Registrar of Vital Statistics p96ert Andrew Curtis(ElectronicallySigned) (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 %/-oT�b3r/ Place of Disposition pi A)a v►?_,,J 2 (address W CC N (section) (Iqt num er) (grave number) (/ Name of Sexton or Person in Charg f Premise 164 MaV/CI d (please print) Ui Signature � Title or�1 DOH-1555(07/18)p 1 of 2 I 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#