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Alexander Sr. James Robert �63b NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex James Robert Alexander Sr. Male Date of Death Age If Veteran of U.S.Armed Forces, 05/15/2020 71 Year War or Dates Place of Death Hospital,Institution or WCity,Town or Village Kingsbury Town Street Address 4 Rock City Road,Kingsbury Town,New York 12839 p Manner of Death ©Natural Cause Accident Homicide Suicide ❑Undetermined ❑Pending W Circumstances Investigation WMedical Certifier Name Title Gerard Abess MD Address 3 Irongate Center,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Kingsbury Town 5762 16 Burial Date Cemetery,Crematory or Facility Name 05/16/2020 Pine View Crematorium Entombment Address 0 Cremation Queensbury Town,New York ElDonation ZO Removal Date Place Removed and/or and/or Held H Hold Address CO) dDate Point of U) ❑Transportation Shipment p by Common 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 Q W (L Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/15/2020 Registrar f Vital Statistics CyntkiaA BarQin(ECectronicady Signed) /signature/ District Number 5762 Place Kingsbury Town, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ~ 4 Z Date of Disposition S 1 IS�2d Place of Disposition ,. W /address) W N (section) �J/lot number/ (grave number) Name of Sexton or Person in Charge of Premise a' �k /ple a print) Z f W Signature Title DOH-1555(07/18)p 1 of 2 i Public Health Law Sec. 4145(�b) Receipt Human remains of _ delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# '- j;,;,