Jackson, Leon NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
'Vital Records Section
Name First Middle Last Sex
Leon Edward Jackson Male
Date of Death Age If Veteran of U.S. Armed Forces,
May 3, 2013 82 War or Dates
H Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address The Pines HCF
Cu Manner of Death El Natural Cause El Accident ❑Homicide El Suicide ❑Undetermined ri❑ Pending
Circumstances Investigation
t,
W Medical Certifier Name Title
ta Patricia Auer,
Address
Queenbury Hudson Headwaters, 12894
Death Certificate Filed District Number Register fytr
City, Town or Village 5601 / y
Date Cemetery or Crematory
®Burial May 7, 2013
❑Entombment Address
['Cremation
Date Place Removed
z ❑ Removal and/or Held
0 and/or Address
'p Hold
0 Date Point of
rt. n Transportation Shipment
(l) by Common Destination
Ct Carrier
Date Cemetery Address
LI Disinterment
'El Reinterment Date Cemetery Address
I
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
E' Remains are Shipped, If Other than Above
Address
i
W`
IX Permission is hereby granted to dispose of the human Gnains d cribed a ve as Indic ed.
Date Issued n5 at, aci Registrar of Vital Statistics
(si re)
District Number 5601 Place ,C;Q 7 L 77 ,
•
I certify that the remains of the decedent identified above wer disposed of in accordance with this ermit on:
I--u
W Date of Disposition 5/7/1 3 Place of Disposition Pine View Cemetery
W (address)
S.I. Sec. 2 29 1
CO
rX (section) (lot number) (grave number)
O connie Goedert
0 Name of S n or Person in Charge of Premises
,�-�A (please print)
ai Signatur �t1 tIVE Title Superintendent
(over)
DOH-1555 (02/2004)