Nesbitt Jr, James NEW YORK STATE DEPARTMENT OF HEALTH `— I3L.
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
James Robert Nesbitt, Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
::' February 24, 2015 47 War or Dates
F- Place of Death Hospital, Institution or
Z;; City, Town or Village Glens Falls Street Address 31 William Street
Manner of Death Natural Cause Accident 0 Homicide 0 Suicide 0Undetermined El Pending
Circumstances Investigation
WT Medical Certifier Name Title
Paul Bachman, M.D.
,, Address
3767 Main Street Warrensburg, NY 12885 ,
Death Certificate Filed District Number Register dumber
ql, City, Town or Village ((moo /w
❑Burial Date Cemetery or Crematory
February 26, 2015 Pine View Crematorium
❑Entombment
Address
`®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
_ Removal
and/or Held
and/or Address
F Hold
Date Point of
�®, ['Transportation Shipment
by Common Destination
0:, Carrier
c, Date Cemetery Address
El Disinterment
` Reinterment Date Cemetery Address
Permit Issued to Registration Number
tsli
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
t�tAddress
l
Permission is hereby granted to dispose of the human remains described above.as indicated.
Date Issued Z J .6 / 15 Registrar of Vital Statistics ..AL,ttpz54z8.,
_ (signature)
District Number v�/ Place 6(e12f ,l/S, ,WA)*
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
iJ Date of Disposition 02/26/2015 Place of Disposition Quaker Road Queensbury,NY 12804
ik (address)
''g''
(section) /dot numb r) (grave number)
tiodi Name of Sexton or Person in Char a of Premises /<hr>>' _3
(phase print)
4#,-14 Signature Title raCj, }7l)-1
(over)
DOH-1555(02/2004)