Fenton, Jarrod NEW YORK STATE DEPARTMENT OF HEALTH 4 S 8 Z
Vital Records Section v.
i Burial - Transit Permit
Name First Middle Last Sex
Jarrod David Fenton Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 2, 2012 33 War or Dates
H Place of Deat l Hospital, Institution or
WCity, Town r Villa e ) Fort Edward Street Address 8 Cooper Street
WManner of Death❑ Natural Cause 0 Accident ElHomicide i l Suicide ❑ Undetermined X❑ Pending
O Circumstances Investigation
W Medical Certifier Name Title
W
Max Crossman, M.D. Dr.
Address
North St. Granville, NY 12832
Death Certificate Filed District Number V Register �ber
City, Town or Village c
❑Burial Date Cemetery or Crematory
November 5, 2012 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
O and/or Address
__ Hold
Date Point of
❑Transportation Shipment
by Common Destination
5; Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Reinterment
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
I— Remains are Shipped, If Other than Above
2 Address
W
a Permission is hereby granted to dispose of the human remains d cribed as indicated.
Date Issued //-,S--d.-v/x--Registrar of Vital Statistic —���` .<___ ,�---/
(signature)
�
District Number,j '2 Place a L %
I certify that the remains of the decedent identified above were disposed of ino accordanceaccordance withwi' this permit on:
W Date of Disposition 'al C,I i2. Place of Disposition 1 L�eO1w,tib(r,ti,.
2 (address)
W
W (section) , . (lot numb (grave number)
• Name of Sexton or P rson in Ch a of Premises r. '�.�,l �r((�
Z (please print)
W Signature Title CIZicarvloroa,
(over)
DOH-1555 (02/2004)