St. Clair, James NEW YORK STATE DEPARTMENT OF HEALTH 1t i
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
James Irving St. Clair Male
3; Date of Death Age If Veteran of U.S. Armed Forces,
;' March 2, 2017 80 War or Dates
= Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital,gal
Manner of Death 0 Natural Cause El Accident 0 Homicide 0 Suicide ri Undetermined � Pending
IA
Circumstances Investigation
, Medical Certifier Name Title
Michael Fuller, M.D
Address
100 Park Street Glens Falls, NY 12801
L Death Certificate Filed District Number Registe�yapper
rw
•° City, Town or Village 5601 �,j
❑Burial Date Cemetery or Crematory
March 7, 2017 Pine View Crematorium
0 Entombment Address
'®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
Removal
and/or Held
and/or Address
',' Hold Pine View Crematorium
Date Point of
❑Transportation Shipment
by Common Destination
Carrier _
' Disinterment Date Cemetery Address
rt IIReinterment Date Cemetery Address
5, Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
': Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped, If Other than Above
s Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 3 ) ? 12011 Registrar of Vital Statistics C,A.' Y'.31.
, (signature)
' . District Number 5601 Place 6 t. .A tc; k \15, eu Y
.. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
u f Date of Disposition 03/07/2017 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
Itit
(section) / (lot number) (grave number)
Name of Sexton or Person in Charge of Premises �Lt1s t '-'L1A1f
Z, 4 (p ease print)
L!1 SignaturepT Title rizt ft1iTtg-
(over)
DOH-1555(02/2004)