Davidson, James F
NEW YORK STATE DEPARTMENT OF HEALTH , 11 An
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
James William Davidson Male
Date of Death Age If Veteran of U.S. Armed Forces,
March 4, 2014 55 War or Dates
Z Place of Death Hospital, Institution or
w City, Town or Village Queensbury Street Address 40 Queen Mary Drive
WManner of Death KI Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
0 Circumstances Investigation
ill i Medical Certifier Name Title
1 Eric Pillemer, M.D. Dr.
Address
102 Park Street Glens Falls, NY 12801
Death 5cate Filed District Number I Register Number
City, ow`� or}Village u�Q9t..,- 21 cl..p� 1
❑Burial // Date Cemetery or Crematory
March 5, 2014 Pine View Crematorium
❑Entombment Address
'®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
; _❑ Removal and/or Held
and/or Address
E Hold
� Date Point of
0. ❑Transportation Shipment
by Common Destination
a Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
El Reinterment
'` Permit Issued to Registration Number
E 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
Remains are Shipped, If Other than Above
Address
Ir
LJ.L"'
-"�° Permission is hereby granted to dispose of the human re ains described ab e s indicated.
: Date Issued Ilaor Registrar of Vital Statistics C_ a ,
y /� (signature)
_
District Number s(0 - ) Place 0 Ct---r O-' a Lk_12_sfi.
I certify that the remains of the decedent identified above were disposed of in accor nc ith this permit on:
Date of Disposition 03/05/2014 Place of Disposition Quaker Road Queensbury,NY 12804
2 (address)
(section) i (lot number&. (grave number)
g
L` Name of Sexton or Person i Charge of Premises rxr
140
l S2nease print)
. Signature 71..- Title 041410e.
(over)
DOH-1555 (02/2004)