Jakway, Roy NEW YORK STATE DEPARTMENT OF HEALTH i
Vital Records Section Burial - Transit ermit
Name First Middle Last Sex
5-7 Roy George Jakway Male
Date of Death Age If Veteran of U.S. Armed Forces,
December 30, 2014 78 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Argyle Street Address 4573 State Rte 40
Manner of Death Rrlu Natural Cause ❑ Accident ❑Homicide ❑ Suicide ❑ Undetermined ❑ Pending
;; Circumstances Investigation
W
Medical Certifier Name Title
CI Edit Masaba,
Address
35 Gilbert Street Cambridge, NY 12816
Death Certificate Filed District Number Register Number
City, Town or Village S75( 61
❑Burial Date Cemetery or Crematory.� January 2, 2015 Pine View Crematorium
❑Entombment Address
a®Cremation Quaker Road Queensbury,NY 12804
., Date Place Removed
z❑ Removal and/or Held
• and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
• Carrier
❑ Disinterment Date Cemetery Address
ElReinterment 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
X.' Name of Funeral Firm Making Disposition or to Whom
E: Remains are Shipped, If Other than Above
Address
Li,
134 E Permission is hereby granted to dispose of the human remains� � described above as indicated.
Date Issued I/aI 3,615 Registrar of Vital Statistics Sn"� iv) � �C�-�
I (signature)
District Number SiS� Place M rJ>le h
J
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F-�
W' Date of Disposition 01/02/2015 Place of Disposition Quaker Road Queensbury,NY 12804
2 (address)
L ,
Gar.
C (section) (lot number) (grave number)
� Name of Sexton or Person in harge of Premises
g‘liii., stiwir-
z (pase print)
LU �i hatl�`�
Signature Title
(over)
DOH-1555 (02/2004)