Hewitt, James NEW YORK STATE DEPARTMLNT OPHEALTH S_5
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
James Drake Hewitt Male
Date of Death Age If Veteran of U.S. Armed Forces,
February 9, 2017 83 War or Dates
Z of Death Hospital, Institution or
W ity Town or Village Glens Falls Street Address Glens Falls Hospital
anner of Death LaiNatural Cause ❑ Accident ❑ Homicide ❑ Suicide 0 Undetermined ❑ Pending
Circumstances Investigation
WJ Medical Certifier Name Title
Robert Hahn, M.D
Address
100 Park Street Glens Falls, NY 12801
De- h Certificate Filed District Number Register Number
own or Village 1 e in S 1'ct- !(c 5601
❑Burial Date Cemetery or Crematory
February 15, 2017 Pine View Crematorium
❑Entombment
Address
• ®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z;❑• Removal and/or Held
• and/or Address
j.., Hold
( Date Point of
a. ❑Transportation Shipment
C4 by Common Destination
8 Carrier
Date Cemetery Address
El Disinterment
❑ Reinterment Date Cemetery Address
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
re
"- Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued Zl t 3 1,i-j Registrar of Vital Statistics l/\.) . ' `s W_A_-*SZQj
(signature)
District Number 5601 Place 6 1�\� �CA l k S
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 02/102017 Place of Disposition Quaker Road Queensbury,NY 12804 ,11 iV% 6 feoreAby
2` (address)
W
-07
te (section) \ t number) (grave number)
in Name of Sexton Person in Charge of Premises �J..1.. �ICvI � c',.�Na-c'-�...�
11 (please print)
W Signature 1.` w� Title - /"'t,en. lc'y D) -,>.le;/-
(over)
DOH-1555 (02/2004)