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Close, Jack Eugene � zc al 41 NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Jack Eugene Close Male Date of Death Age If Veteran of U.S.Armed Forces, 01/07/2022 77 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Queensbury Town Street Address 34 S Western Ave,Queensbury Town,New York 12804 `p Manner of Death ©Natural Cause Accident ❑Homicide ❑Suicide Undetermined El Pending Circumstances Investigation W Medical Certifier Name Title O Sonya Blackmer NP Address 2 Irongate Center,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 5 ❑Burial Date Cemetery,Crematory or Facility Name 01/10/2022 Pine View Crematorium Entombment Address X❑Cremation Queensbury Town,New York ❑Donation Removal Date Place Removed and/or and/or Held N Hold Address 0 d Date Point of �l! ❑Transportation Q by Common Shipment Carrier Destination Disinterment Date Cemetery Address rr . Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O. Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom I- Remains are Shipped,If Other than Above 1 Address cc W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/09/2022 Registrar of Vital Statistics Caroline rfildegarde Barber(ECectronicalTy Signed) (signature) District Number 5657 Place Queensbury, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition I/II I'LZ Place of Disposition 2 (address) lilt N (section) /lot number) (grave number) Name of Sexton or Person in Charge of Premis �1M nt� (pie e print) W Signature Title COElifyirtg DOH-1555(07/18)p 1 of 2 t , r 0 . 5 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 1 t Pine View Cemetery Representing the funeral home named on buyial9permit Official Funeral Directors Reg. or License#