RuckerJr., Jackie Lynn NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Jackie Lynn Rucker Jr Male
Date of Death Age If Veteran of U.S.Armed Forces,
10/06/2020 51 Years War or Dates
�.. Place of Death Hospital,Institution or
Z City,Town or Village Hudson Falls Village Street Address 351/2 Pine Street,Hudson Falls Village,New York 12839
WW Manner of Death Ei
Natural Cause Accident Homicide Suicide Undetermined Pending
U Circumstances Investigation
UJ Medical Certifier Name Title
Robert Lemieux Coroner
Address
415 Lower Main Street,Hudson Falls Village,New York 12839
Death Certificate Filed District Number Register Number
City,Town or Village Hudson Falls Village 5726 34
❑Burial Date Cemetery,Crematory or Facility Name
10/09/2020 Pine View Crematorium
Entombment Address
lCremation Queensbury Town,New York
Donation
o ❑Removal Date Place Removed
and/or and/or Held
- Hold Address
0
Q.
❑Transportation Date Point of
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 or to Whom
Remains are Shipped,If Other than Above
2 Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/09/2020 Registrar of Vital Statistics Cynthia cBard n g(ectronicafySigned)
(signature)
District Number 5726 Place Hudson Falls Village, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ZW Date of Disposition Pip 7,6 Place of Disposition
2 Vaddress)
uJ
1n
CC (sedan) (/otnumbed (grave number)
gName of Sexton or Person in Charge of P ises c_041%14
Z lease print/
W Signature Title G /41
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DOH-1555(07/18)p 1 of 2
i s
Public Health Law Sec. 4145(2b) 014 0 9 4
Receipt
•
Human remains of • ` ' delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#