Latterell Jr., Jesse NEW YORK STATE DEPARTMENT OF HEALTH . it 30
Vital Records Section Burial - Transit Permit
',,P Name First Middle ' Last Sex
Jesse Isodore Latterell, Jr. Male
Date of Death Age - If yeteran of U.S. Armed Forces,
June 1, 2017 85 .,War or Dates
Place of Death Hospital, Institution or
ut City, Town or Village Moreau Street Address 18 White Burch Estates
Manner of Death X❑Natural Cause ❑ Accident ElHomicide ❑ Suicide ❑ ❑ Pending
CircumstancesUndetermined Investigation
t.0 Medical Certifier Name Title
Philip Gara, M.D. Dr.
Address
7,- Broadway Fort Edward, NY 12828
�. Death Certificate Filed District Nu RegisteiJ tuber
City, Town or Village
774❑Burial Date Cemetery or Crematory
It June 5, 2017 I Pine View Crematorium
0 EntombmentIx!ivi Address
Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑
Removal and/or Held
and/or
} Hold Address
iivii, Union Cemetery
Date Point of
af❑Transportation Shipment
by Common Destination
15; Carrier
` ❑ Date Cemetery Address
Disinterment
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
15 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
Remains are Shipped, If Other than Above
21 Address
°W
Permission is hereby granted to dispose of the human rem ' scrib I a%ove as indicated.
Date Issued 6(O/OSP0/7 Registrar of Vital Statisti s ft if�� �/y� signature)
District Number (Npo� 351 s le1a /a7 �
Place /nôfcf / � h,('
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
aDate of Disposition 06/05/2017 Place of Disposition Quaker Road Queensbury,NY 12804
'2g (address)
'CA'
LE (section) (lot number) (— (grave number)
jry Name of Sexton or Person in Charge of P emises �i4/q3 - —3 rt✓ol iIf
(ple a print)
Wt Signature / Title Mf NA
(over)
DOH-1555 (02/2004)