Boldt, Jason A. (2) NEWYORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Jason A.Boldt Male
Date of Death Age If Veteran of U.S.Armed Forces,
03/20/2020 39 Years War or Dates
F. Place of Death Hospital,Institution or
WCity,Town or Village Northumberland Town Street Address 3 James Court A,Northumberland Town,New York 12831
"p Manner of Death Natural Cause ❑Accident ❑Homicide Suicide ❑Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
0 David DeCelle Coroner
Address
40 McMaster Street,Ballston Spa,New York 12020
Death Certificate Filed District Number Register Number
City,Town or Village Northumberland Town 4563 5
Burial Date Cemetery,Crematory or Facility Name
03/24/2020 Pine View Crematory
Entombment Address
0 Cremation Queensbury Town,New York
Donation
� �Removal Date Place Removed
and/or and/or Held
F—FA Hold Address
O
4. 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 Compassionate Funeral Care Inc 00364
Address
402 Maple Ave,Saratoga Springs,New York 12866
Name of Funeral Firm Making Disposition orto Whom
Remains are Shipped,If Other than Above
Address
W
I' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/24/2020 Registrarof Vital Statistics Deniw DMz,,plty(Eke-tronicaf Stgned)
(signature)
District Number 4563 Place Northumberland Town, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition Place of Disposition r+ JC C
Uj (a s)
W
N (section) (lot num/ber) (grave number)
0 Name of Sexton or Person in Char f Premis ' w�
/please print/
LU
W Signature Title
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) r 013459
Receipt
Human remains of delivered on ' '' 20 Z
Pine vie , Cemetery Representing the funeral home named on,burial
Official Funeral Directors Reg.or License# ;