McDonald, Jesse NEW YORK STATE DEPARTMENT OF HEALTH 1 -PA
Vital Records Section 3: Burial - Transit Permit
Name First Middle Last Sex
Jesse James McDonald Male
Date of Death Age If Veteran of U.S. Armed Forces,
10/10/2016 24 years War or Dates
;- Place of Death Hospital, Institution or
City, T ‘OR4XMX Saratoga Springs Street Address Saratoga Hospital
Manner of Death ID Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
lit Circumstances Investigation
ILI Medical Certifier Name Title
0 J Robert Hayes M D.
Address
211 Church Street Saratoga Springs, N. Y. 12866
Death Certificate Filed District Number Register Number
City, Two(XiYagiex Saratoga Springs 4501 477
❑Burial Date Cemetery or Crematory
❑Entombment 10/17/2016 Pine View Crematorium
Address
[Cremation Queensbury, N Y
Date Place Removed
Z' Removal and/or Held
2�and/or Address
CO Hold
Q Date Point of
ti ❑Transportation Shipment
G3 by Common Destination
M. Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
68 Main St, Po Box 67, Hudson Falls, Ny 12839
Name of Funeral Firm Making Disposition or to Whom
1Remains are Shipped, If Other than Above
2 Address
it
III
197. Permission is hereby granted to dispose of the human repo]ns describecMbove as indicated.
Date Issued 10/12/2016 Registrar of Vital Statistics L---_, -4-1,2„...k
i -
(signature)
District Number 4501 Place Saratoga Springs
F-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
CDate of Disposition fDllgllb Place of Disposition ,� �c�m ,
111
(address)
fa
CC (section) / (lot number) (grave number)
ta Name of Sexton or Person in Charge of Premises `ih3 /' 5se^l .1
yplease
print)
I GL Signature Title C -P ebt (over)
DOH-1555 (02/2004)