Persons, Arthur James Vawe:v'
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NEW YORK STATE DEPARTMENT OF HEALTH e i
Bureau of Vital Records ' " Burial - Transit Permit
Name First Middle Last Sex
Arthur James Persons Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/03/2023 66 Years War or Dates Army
i— Place of Death Hospital,Institution or
In
Z City,Town or Village Queensbury Town Street Address 11 Leo Street,Queensbury Town,New York 12804
p Manner of Death El Natural Cause Accident Homicide OSuicide Fpndetermined riPending
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V Circumstances Investigation
0 Medical Certifier Name Title
Thomas Coppens MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed Town Of Queensbury District Number J Register Number
City,Town or Village 5657 2
BurialEl
Date Cemetery,Crematory or Facility Name
01/05/2023 Pine View Crematory
Entombment Address
▪Cremation Queensbury,New York
Donation
z Date Place Removed
ei❑Removal and/or Held
4- and/or
N Hold Address
Transportation Date Point of
0S❑by Common Shipment
Carrier Destination
EDisinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
2 Address
It
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O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/05/2023 Registrar of Vital Statistics Carotin.7aegardeBar6er(E(ectronicaffySigned)
(signature)
District Number 5657 Place Town Of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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Date of Disposition ((� 73 Place of Disposition _.....{ .-k /* b�--,
2 (address)
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O (section) A.,
(lot number) (grave/grave number)
ccG Name of Sexton or Person in Charg Premises /�
Z /p/ se print/ill
rint/ ,�.�}t
illSignature0 Title
DOH-1555(07/18)p 1 of 2
4 L1. 6 5 6 6
Public Health Law Sec. 4145(2b)
Receipt
1
Human remains of delivered on , 20
1
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg. or License#
1