Hadley, James NEW YORK STATE DEPARTMENT OF HEALTH t k 13
Vital Records Section Burial - Transit Permit
f Name First Middle Last Sex
James Thomas Hadley Male
Date of Death Age If Veteran of U.S. Armed Forces,
4 01/11/2014 38 War or Dates
Place of Death Hospital, Institution or
i'4 City, Town or Village GLENS FALLS Street Address GLENS FALLS HOSPITAL
Manner of Death❑ Natural Cause 0 Accident 0 Homicide 0 Suicide El Undetermined Pending
Circumstances Investigation
Medical Certifier Na Titje
'-''''''. //frIT;47 ''-Address ��
Certificate Filed / f ��/� District Numj� Register mbe
r Cit own or Village ` f 6. .�
t
Burial Date C or Crem,�ory ��
P Entombment / ��/ ��-P l/6 (/1,/,m"�/dr-,rJ<-s-j
Address / /®Cremation (i--Can f ./ �J
Date -' Place Removed
Removal and/or Held
and/or Address
Hold
Date Point of
it..❑Transportation Shipment
t : by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00141
Address
9 Pine St/P.O. Box 455 Chestertown NY 12817
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is herby anted to dispose of the human remains describ�ecj.a Qvq�aL�C di2�
Date Issued / / / /� Registrar of Vital Statistics / T
(signature)
District Number Place 6/.4z>. .�i A /0y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 1/flIIN Place of Disposition wi),tu (M,c,0r it-
(address)
lit
01,
(section) (lot number) (grave number)
" F Name of Sexton or Person inCharge of Pr mises s visit
lease print)
G/ 4.=+r
Signature �' Title C2_ «trac
(over)
DOH-1555(02/2004)