Jones Sr., Everett NEW YORK STATE DEPARTMENT OF HEA •
p L ID
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Everett William Jones Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
August 20, 2017 80 War or Dates Korea
�.. Place of Death Hospital, Institution or
It City, Town or Village Moreau Street Address Home of the Good Shepherd
Manner of Death 1..... Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
o Circumstances Investigation
ill Medical Certifier Name Title
Joseph Foote MD,
Address
Rt 4 Hudson Falls, NY 12839
Death Certificate Filed Distri Ny�b Regi t r I)Ilumber
City, Town or Village S�(pp c'
❑Burial Date Cemetery or Crematory
August 25, 2017 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
E, Hold
Date Point of
IL ❑Transportation Shipment
0) by Common Destination
p! Carrier
ElDisinterment Date Cemetery Address
;, El Reinterment Date Cemetery Address
7 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
#- Remains are Shipped, If Other than Above
Address
i
i.- Permission is hereby ranted to dispose of the human remain escribe b e as indicated.
7-4 Date Issued 0 201 Registrar of Vital Statistic 1004
(sig ature)
District Number t5&A Place a5/ /Q nO/Ct'/S Qye ,/ q. Ida
-Y:
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 08/25/2017 Place of Disposition Quaker Road Queensbury,NY 12804
W2< (address)
CO
iX (section) (lot number) (grave number)
tName of Sexton or Person in Charge of Pre ises ((t.4Up1„� a^1�W�
(pie jse pent)`
W Signature m Title G fik4inK
(over)
DOH-1555 (02/2004)