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Hesse Jr., Donald William 1 NEWYORKSTATEDEPARTMENTOFHEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Donald William Hesse Jr. Male Date of Death Age If Veteran of U.S.Armed Forces, 05/23/2021 59 Years War or Dates i.. Place of Death Hospital,Institution or WCity,Town or Village Moreau Town Street Address 9 Columbine Avenue, Moreau Town, New York 12803 pManner of Death ©Natural Cause 0 Accident ❑Homicide ❑Suicide 0 Undetermined ❑Pending U Circumstances Investigation Q Medical Certifier Name Title Mark Doyle MD Address 377 Church Street,Saratoga Springs,New York 12866 Death Certificate Filed District Number Register Number City,Town or Village Moreau 4562 27 0 Burial Date Cemetery,Crematory or Facility Name 05/28/2021 Pine View Crematorium Ei Entombment Address 0 Cremation Queensbury Town,New York ElDonation ZO El Removal Date Place Removed and/or and/or Held = Hold Address 0 d. Date Point of Cl) LI Transportation p by Common Shipment Carrier Destination 0 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 Address CC Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/27/2021 Registrar of Vital Statistics Leeann Mc cabe(E(ectronica((y Signed) (signature) District Number 4562 Place Moreau, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition 10/I 17 I Place of Disposition 2 (address) W CC (section) lot number) (grave number) Name of Sexton or Person in Charge of Pre, ►'ifs L f4tt Z (pleas print) /' W Signature Title L� 'gri9K DOH-1555(07/18)p t of 2 Public Health Law Sec. 4145(2b) 1.it 8 c 3 Receipt Human remains of r delivered on. , 20 Pine View Cemetery Representing the funeral home named on burial pe Official Funeral Directors Reg.or License#