Stoy, James NEW YORK STATE DEPARTMENT OF HE.
Vital Records Section Burial - Transit Permit
— Name First idle Last Sex
James Archie Stay male
Date of Death If Veteran of U.S. Armed Forces,
Oct 9, 2011 L 111 War or Dates _o_
Place of Death Hospital, Institution or
L!J City, -mciwzimfrazspc Glens Falls
Street Address Glens Falls Hospital
W' Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
0 Robert Sponzo, MD
Address
Glens Falls, NY
Death Certificate Filed District Number Regist9r,Ny�ber
City, git Glens Falls 5601 5lS
0 Burial Date Cemetery or Crematory
Oct 11 , 2011 Pine View Crematorium
❑Entombment Address
EaCremation Th of Queensbury, NY
Date Place Removed
z
❑ Removal and/or Held
and/or Address
l.. Hold
0 Date Point of
a ❑Transportation Shipment
00 by Common Destination
In: Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
El Reinterment
r Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
68 Main St., Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
IX
CL Permission is hereby granted to dispose of the human remains des i ed bov sin .
Date Issued .40/12ol/ Registrar of Vital Statistics � �
(signature)
District Number 5601 Place City of Glens Falls, NY
• I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition (n/it lit Place of Disposition Phu( Cr' +oriv.�.
(address)
wCO
Ce (section) n _ (lot numb4 (grave number)
0• Name of Sexton or Pers n in Charge of emises i 4thr e.i at
(please print)
W Signature P L - Title Clew+i o-
(over)
DOH-1555 (02/2004)