Guerrera, Jack NEW YORK STATE DEPARTMENT OF HEALTH 'rl
Vital Records Section - Burial - Transit Permit
Name First Middle Last Sex
Jack Vincent Guerrera Male
Date of Death Age If Veteran of U.S. Armed Forces,
February 8, 2015 84 War or Dates World War II
�.- Place of Death Hospital, Institution or
wy City, Town or Village Glens Falls Street Address Glens Falls Hospital
0.W. Manner of Death X❑ Natural Cause El Accident El Homicide El Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
CI Joseph Foote MD,
Address
Rt 4 Hudson Falls, NY 12839
Death Certificate Filed District Number Register Nuuher
- ' City, Town or Village ,5-6a-i
❑Burial Date Cemetery or Crematory
February 11, 2015 Pine View Crematorium
;_ ❑Entombment Address
y ®Cremation Quaker Road Queensbury,NY 12804
2, ❑ RDate Place Removed
emoval and/or Held
and/or Address
j Hold
ST) Date Point of
j;, ❑Transportation Shipment
0 by Common Destination
0 Carrier
Date Cemetery Address
W ❑ Disinterment
❑ 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
fir:
Remains are Shipped, If Other than Above
Address
W'
tle: Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 21 l 1 / 4.5 Registrar of Vital Statistics LA, (-, Q'A)
(signature)
District Number S:,/ Place Glens Al4J1 /'i' V /acp/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H
1 :
;W' Date of Disposition 02/11/2015 Place of Disposition Quaker Road Queensbury,NY 12804
2 (address)
LLJF,
lr (section) / lot number) (grave number)
aName of Sexton or Person in Charge of Premises G ,, SewAtif
z 4 L (plebse
', Signature -- Title Crt.E.,oil 1�(,
(over)
DOH-1555 (02/2004)