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Jetter Sr., Paul Henry 4 till "../d NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Vital Records Burial - Transit Permit Name First Middle Last Sex Paul Henry Jetter Sr. Male Date of Death Age If Veteran of U.S.Armed Forces, 05/05/2023 83 Years War or Dates i_ Place of Death Hospital,Institution or W City,Town or Village Glens Falls Street Address Glens Falls Hospital 13 Manner of Death Natural Cause Accident ❑Homicide OSuicide Undetermined Pending ILI Circumstances Investigation W Medical Certifier Name Title CI Mathew Varughese DO Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed City Of Glens Falls District Number Register Number City,Town or Village 5601 239 Burial Date Cemetery,Crematory or Facility Name 05/09/2023 Pine View Crematory Entombment _ Address ©Cremation Queensbury,New York Donation ZO❑Removal Date Place Removed and/or and/or Held H Hold Address N 0 d Date Point of (/)OTransportation Shipment 5 by Common Carrier Destination Disinterment Date Cemetery Address El 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 -. Remains are Shipped,If Other than Above 2 Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/09/2023 Registrar of Vital Statistics Megan No(in(ECectronica1Ty 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: ZIL Date of Disposition SI el 123 Place of Disposition ��,,.,�„ (address) W NCC (section) (lot number) (grave number) 0 Name of Sexton or Person in Charge of Premises �f•4;1— Nf<---r/ lease print) lL Lam' TitlefGi.rn.{�� Signature DOH-1555(07/18)pi of 2 9 1, Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 Pine View Cemetery, Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#