Jackson, John A •
16202
Public Health Law Sec. 4145(2b) •
Receipt
Human remains of delivered on , 20 `
Pine View Cemetery Representing the funeral home,rfamed on burial permit
Official Funeral Directors Reg. or License#
4
.ij A (t T -
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Middle Last Sex
Name First Male
John A Jackson
Date of Death I Age If Veteran of U.S.Armed Forces,
08/30/2022 90 Years I War or Dates 1950-1954
Place of Death HospitaL Institution or
Z City,Town or Village Glens Falls
Street Address Glens Falls Hospital
W Manner of Death Undetermined ❑Pending
IQ EINaturalCause ❑Accident �Hornicide Suicide ❑Circumstances Investigation
C) Title
ILI CI Medical Certifier Name
William Cleaver MD
Address
100 Park St,Glens Falls,New York 12801
DeaBth Certificate Filed City Of(ins Falls District Number • Register Number
City,Town or Village _ 5601 445
Burial Date Cemetery,Crematory or Facility Name Vie
w
Pine Crematorium
Entombment Address
Cremation Queensbury Town,New York
Donation
Z Date Place Removed
Removal and/or Held
IF- and/or
CD
Address
0
Q. Date Point of
N❑Transportation Shipment
p by Common
Carrier Destination
Date Cemetery Address
❑Disinterment
Date Cemetery Address
0 Reinterment
Permit Issued to Registration Number
Name of Funeral Home Radloff Funeral Home Inc 01425
Address
136 Warren St,Glens Falls,New York 12801
Name of Funeral Firm Making Disposition or to Whom
i . Remains are Shipped,If Other than Above
a Address
OC
Q. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued O8/31/2022 Registrar of Vital Statistics ategan✓'roltn4'kt-trimu' Sfyned)
(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:
fW Date of Disposition q i 1 I 17_ Place of Disposition fI i µ
(address)
W
U) (section) /7 ,(lot number) (grave number)
Name of Sexton or Person in Charge of P miles C "�
Z ( ease prat)
Z
iiJ Signature �/ Title 7Ptfi
y` i
uuii 555 Cur/e69p i orz014