Jensen, George Peter NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
George Peter Jensen
Male
Date of Death Age If Veteran of U.S.Armed Forces,
05/17/2022 79 Years War or Dates 1963-2003
Place of Death Hospital,Institution or
Z
City,Town or Village Glens Falls Street Address Glens Falls Hospital
0 Manner of Death ❑X Natural Cause Accident 11=1 Homicide El Suicide FlUndetermined ❑Pending
ILI
0 Circumstances Investigation
W Medical Certifier Name Title
0 Marcille Labban MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
_,A City,Town or Village 5601 271
X Burial Date Cemetery,Crematory or Facility Name
e 05/21/2022 Pine View Cemetery
Entombment
_ Address
Cremation Queensbury Town,New York
DDonation
O❑Removal Date Place Removed
and/or and/or Held
h Hold Address
ut
Date Point of
W4Transportation Shipment
ES by Common
Carrier Destination
Date Cemetery Address
Disinterment
El 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
Remains are Shipped,If Other than Above
5 Address
Q
W
d Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/19/2022 Registrar of Vital Statistics Megan Nofln(E1 ctronicalTy Signed)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: \\
2 Date of Disposition 5•a t a a Place of Disposition al ('1 ►Q\Cc-Q (`�1►,v 1 t,,,j iA.Ail
a. (address) ..J
fie (section) lot number) (grave number)
Name of Sexton or Person in Charge of Premise On n i C c-,i�4-
8 (please print) '
w Signature ____ se Title ` u�'CJ In cte_lT/—
DOH-1555(07/18)p t of 2
Public Health Law Sec. 4145(2b)
012918
Receipt
Human remains of delivered on .. I , 20
/ /,,
Pi a View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
JENSEN
NAME George Peter Jensen Age: 79
Lot Owner: G. Peter & Sharon Jensen
Lot# Erie 1 5D Grave# 1
Case: Concrete
Died: 5.1 7.2 2 Interred: 5.21 .2 2
Funeral Home: Carleton FH
Cemetery: Pine View
JENSEN
Owner
G.Peter & Sharon Jensen
Address Plot
17 West Rd, South Glens Falls, NY 12803 Erie
Phone # Lot #
518-798-3859 15 D
Deed # Date
4278 7/27/2021
Cost Foundation Y - N
$2250.00
Location West-Romer
East-Vacant
North-Vacant
South-Vacant
Remarks
I ACKNOWLEDGE THE RECEIPT OF THE RULES AND REGULATIONS OF THE
PINE VIEW CEMETERY: _ ,
SIGNATURE: DATE: //2 V2 �J�
SIGNATURE: / Lvn� r� ��e-,-� DATE: G 7 0 A
Record of Interments
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