Carlton, James Michael # —)0
NEWNEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
James Michael Carlton Male
Date of Death Age If Veteran of U.S.Armed Forces,
05/22/2021 40 Years War or Dates
�.. Place of Death Hospital,Institution or
Z City,Town or Village Hudson Falls Village Street Address 50 Margaret Ext.Street,Hudson Falls Village,New York 12839
W
`p Manner of Death Natural Cause ❑Accident Ej Homicide Suicide ElUndetermined Pending
✓ Circumstances Investigation
CI
Medical Certifier Name Title
Robert Lemieux Coroner
Address
415 Lower Main Street,Hudson Falls Village,New York 12839
Death Certificate Filed District Number Register Number
City,Town or Village Hudson Falls Village 5726 14
❑Burial Date Cemetery,Crematory or Facility Name
06/04/2021 Pine View Crematorium
❑Entombment Address
lCremation Queensbury Town,New York
El Donation
o ❑Removal Date Place Removed
and/or and/or Held
- Hold Address
CO
0
O. Date Point of
N ❑Transportation
by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address
68 Main Street,P.O.Box 67,Hudson Falls,New York 12839
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
2 AddressCC Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/27/2021 Registrar of Vital Statistics CyntkiaABar&n(ECectronicaCCySigned)
(signature)
District Number 5726 Place Hudson Falls Village, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition Wit Place of Disposition
/adlress)
W
CC CC (section) (lot number) rave number)
• Name of Sexton or Person in Charge of ises w � -.5
Z (plea riot)
W Signature Title C►refA
DOH-1555(07/18)pi of 2
-
Public Health Law Sec. 4145(2b) 4 8 3 i
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#