Stone, Jay NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
a Jay Ellison Stone Male
ti Date of Death Age If Veteran of U.S. Armed Forces,
March 20, 2015 81 War or Dates Korea Other
Place of Death Hospital, Institution or
City, Town or Village C.t.eh Pi.j.(S Street Address
jal Manner of Death 0 Natural Cause El Accident n Homicide 0 Suicide El Undetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
Wendy Steinhacker,
Address
9 Carey Road Queensbury, NY 12804
Death Certificate Filed ' J ) ,� (District Number Register Nytx�r
iG�`t Mown or Village ( 4) /0
❑Burial Date Cemetery or Crematory
March 25, 2015 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
ri Removal and/or Held
t" and/or
Hold Address
Date Point of
_;❑ Transportation Shipment
by Common Destination
telii
_ Carrier
Disinterment
Date Cemetery Address
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
z72-1 Address
h
u Permission is hereby granted to dispose of the human remains de rr b, d bov i dicated.
Date Issued3�i�2CJ/)' Registrar of Vital Statistics =ry `;%'�
(signature)
. District NumberokY/ Place 642$,i 74s, Mt
e
A: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
r Date of Disposition 03/24/2015 Place of Disposition Quaker Road Queensbury,NY 12804 1jv,€j14,..1, . /4
(address)
leifi
(section) 6 Y num.,� d (grave number)
Name of Sexton or P r remsesarge of PiTint)Ii Signature Title f 4S 7 -
(over)
DOH-1555 (02/2004)