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Amir, Jack Lgi NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Jack Amir Male Date of Death Age If Veteran of U.S.Armed Forces, 08/23/2023 96 Years War or Dates Navy ZPlace of Death Hospital,Institution or City,Town or Village Queensbury Town Street Address 38 Lyon Court,Queensbury Town, New York 12804 p• Manner of Death ❑X Natural Cause Accident Ei Homicide Suicide Undetermined Pending U Circumstances Investigation Q Medical Certifier Name Title Aimee Mcmaster NP Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed Town Of Queensbury District Number Register Number City,Town or Village 5657 131 Burial Date Cemetery,Crematory or Facility Name 08/25/2023 Pine View Crematory Entombment Address ©Cremation Queensbury,New York Donation ❑Removal Date Place Removed and/or and/or Held N Hold Address O O. Date Point of Cl) Transportation by Common Shipment Carrier Destination Disinterment 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 f. 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 08/24/2023 Registrar of Vital Statistics Caroline x(degarde Barber(Electronically Signed) (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: Z Date of Disposition 9—V-zOL3 Place of Disposition 'Pt',J e e",) e/'Gm44y(� 2 (address) W CC (section/ (lot number) (grave number) Q1 O Name of Sexton or Person in Charge Premi s �Y•7D,� Lr/O(�('' Z II (please print W ai Signature Title D e 770 lr DOH-t555(07/18)p t of 2 7 2 --.r.L.'r 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#