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Labutta, Jason Eric NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records --_— Name First Middle Last Sex Jason Eric Labutta Male Date of Death Age If Veteran of U.S.Armed Forces, 12/19/2021 42 Years War or Dates F. Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address 122 Cooper Street,Glens Falls,New York 12801 p Manner of Death El Natural Cause ❑Accident El Homicide ❑Suicide ❑Undetermined ©Pending Circumstances Investigation W Medical Certifier Name Title Timothy Murphy Coroner Address 52 Haviland Avenue,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 617 0 Burial Date Cemetery,Crematory or Facility Name 12/30/2021 Pine View Cemetery ❑Entombment Address • Cremation Queensbury Town,New York ❑Donation gRemoval Date Place Removed and/or and/or Held F - part Address O 4. Date Point of t/) Li Transportation Ira 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 1— Remains are Shipped,If Other than Above 5 Address W a' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/22/2021 Registrar of Vital Statistics Robert Andrew Curtis(EfectronicaltySigned) (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: �A Z Date of Disposition j a j Place of Disposition C 2/ a),�'�CL 1W auel1SJr' NN f q) - 2 (address) W link? I COr) (secti � (lot number) (grave number) 0 / Name of Sexton r Person in Charge of Premises Or1�l e L�vec .e,O- Z (please print) W Signature {4Q C P � t�V Title Sl at' RX-1c t)111 DOH-1555(07/18)p t of 2 Public Health Law Sec. 4145(2b) 012890 Receipt Human remains of r delivered on ;;._ , i � f Pine View Cemetery Representing the funeral home named on burial permit Official - Funeral Directors Reg.or License# / LaButta .- NAME Jason Eric Labutta Age: 42 Lot Owner: Jason Labutta ((DSS) Lot# Horicon 20 F Grave# 1 Case: Concrete Died: 1 2. 1 9.21 Interred:1 2 .3 0 .21 Funeral Home: Baker FH Cemetery: Pine View