Cole, Jayceon NEW YORK STATE DEPARTMENT OF HEALTH # (49 Z
Vital Records Section y Burial - Transit Permit
Name First Middle Last Sex
Jayceon Taylor Cole Male
Date of Death Age If Veteran of U.S. Armed Forces,
September 17, 8201 4609 "1.41+1/4, War or Dates
Place of Death Hospital, Institution or
uj City, Town or Village Glens Falls Street Address Glens Falls Hospital
0 Manner of Death❑ Natural Cause E Accident EHomicide D Suicide ❑ Undetermined 2 Pending
tUJ
a' Circumstances Investigation
W Medical Certifier Name Title
O Michael Sikirica MD,
Address
50 Broad Street Waterford, NY 12188
Death Certificate Filed District Number Register Number
City, Town or Village 5601 i--{2q
❑Burial Date Cemetery or Crematory
September 21, 2012 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
}- Hold
09 Date Point of
Transportation Shipment
0) by Common Destination
3 Carrier
Disinterment Date Cemetery Address
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
I--: Remains are Shipped, If Other than Above
2 Address
IX
t Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued y ram./ ((2 Registrar of Vital Statistics LA �,w
(sign ture)
District Number 5601 Place 6 C_ rcA 1\S) NI y falai
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W; Date of Disposition °I IZS)IZ Place of Disposition g-iLLA---• j -4 1 t ,_
2L (address)
WCe'
(lot nu r) (grave number)
Q (section) t
Z
0 Name of Sexton or Pers►n in Charge of mises ifir
(please print)
W Signature ,v Title ""`'.N'tT 6 ",l-
(over)
DOH-1555 (02/2004)