Loading...
Straight, Jack Junior zl NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Jack Junior Straight Male Date of Death Age If Veteran of U.S.Armed Forces, 03/21/2024 65 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Hudson Falls Village Street Address 3 Boulevard, Hudson Falls Village,New York 12839 ILI O Manner of Death ❑^ Natural Cause Accident El Homicide []Suicide Undetermined ❑Pending Circumstances Investigation W Medical Certifier Name Title John Stoutenburg MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed Village Of Hudson Falls District Number Register Number City,Town or Village 5726 12 []Burial Date Cemetery,Crematory or Facility Name 03/25/2024 Plne View CrematoryEntombment Address ©Cremation Queensbury Town,New York [ ]Donation ZZ❑Removal Date Place Removed - and/or and/or Held N Hold Address 0 d Date Point of (/) Transportation CI Common Shipment Carrier Destination O Disinterment Date Cemetery Address Date Cemetery Address []Reinterment Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls • 01078 Address 136 Main St,S Glens Falls,New York 12803 Name of Funeral Firm Making Disposition or to Whom j— Remains are Shipped,If Other than Above ."a Address CC I1J a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/25/2024 Registrar of Vital Statistics Cynthia A Bardin(Electronically Signed) (signature) District Number 5726 Place Village Of Hudson Falls I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: IH Z Date of Disposition 3inizN Place of Disposition -P;,.,r,,r,,.,....j I 'AATwzti.'� (address) W N CC (section) (lot number) (grave number) Aa • Name of Sexton or Person in Charge of Premises ^"++/ (p ase pr W Signature Title Fic DOH-1555(07/18)p 1 of 2 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#