Yole, Jeffrey NEW YORK STATE DEPARTMENT OF HEALTH 4 .
Vital Records Section Burial - Transit ermit
Name First Middle Last Sex
Jeffrey Edward Yole Male
Slt Date of Death Age If Veteran of U.S. Armed Forces,
April 6, 2017 55 War or Dates
Place of Death Hospital, Institution or
`r City, Town or Village Albany Street Address Albany Medical Center
Manner of Death Natural Cause ❑ Accident ElHomicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
44
Thomas Holman, M.D
Address
43 New Scotland Ave. Albany, NY 12208
Death Certificate Filed District Number Register Number
City, Town or Village . j 0I g u 2...
❑Burial Date Cemetery or Crematory
April 10, 2017 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
' and/or Address
47 Hold
Date Point of
-611
❑Transportation Shipment
tld, by Common Destination
l Carrier
❑ Disinterment
Date Cemetery Address
❑ Reinterment Date Cemetery Address
Ati
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
mil
:=i-cm Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
ti Name of Funeral Firm Making Disposition or to Whom
'1 Remains are Shipped, If Other than Above
;a, Address
Ir
Permission is hereby ranted to dispose of the human remai described above as indicated.
/ r 7 Registrar of Vital Statistics //'��
. Date Issued - _"
(signature)
District Number jO I Place C11 o i- A-l;`L`I
to /
*, I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
,` Date of Disposition 04/10/2017 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
teJ (section) `, blot number (grave number)
NikName of Sexton or Person in Charge of remises ` �r s Z"i l
lt-
/lA (pease print)
Signature L�� 9, Title
(over)
DOH-1555 (02/2004)