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Archambault, James Albert 71F NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex James Albert Archambault Male Date of Death Age If Veteran of U.S.Armed Forces, 02/12/2020 90 Years War or Dates H Place of Death Hospital,Institution or WCity,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc p Manner of Death ©Natural Cause Accident Homicide ❑Suicide Undetermined Pending Circumstances Investigation WMedical Certifier Name Title Philip Gara MD Address 319 Broadway,Fort Edward Town,New York 12828 Death Certificate Filed District Number Register Number City,Town or Village Fort Edward 5755 12 Burial Date Cemetery,Crematory or Facility Name 02/14/2020 Pine View Crematorium QEntombment Address KCremation Queensbury Town,New York Donation ZO Removal Date Place Removed and/or and/or Held H Hold Address N O d Date Point of N ❑Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition orto Whom F. Remains are Shipped,If Other than Above Address Ix W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/14/2020 Registrar of Vital Statistics Aimee Mahoney(ECectronicaCCySiyned) (signature/ District Number 5755 Place Fort Edward, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition Z /y 1Zp Place of Disposition , C CI,.— W 2 (address/ W N (section) 44(lotiberg (grave number/ 0Name of Sexton or Person in Charge of Premises ns Z (plealle prin W Signature Title DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) ..3 3 4 11 Receipt Human remains of r,dilivered on 1 , 20 i Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#