Loading...
Porter, Jeffrey Michael NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Jeffrey Michael Porter Male Date,of Death Age If Veteran of U.S.Armed Forces, 08/29/2021 62 Years War or Dates 2004-2006 Place of Death Hospital,Institution or W City,Town or Village Fort Ann Town Street Address 184 Burquist Road,Fort Ann Town,New York 12827 `p Manner of Death ©Natural Cause Accident ❑Homicide ❑Suicide 0 Undetermined 0 Pending Circumstances Investigation W Medical Certifier Name Title O William Tedesco MD Address 3 Irongate Center,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Fort Ann 5754 8 ❑Burial Date Cemetery,Crematory or Facility Name 09/02/2021 Pine View Crematorium ❑Entombment Address 1 Cremation Queensbury Town,New York Donation zRemoval Date Place Removed and/or and/or Held l- Hold Address 0 d Date Point of Cl) ❑Transportation p by Common Shipment Carrier Destination 11 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 W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 09/02/2021 Registrar of Vital Statistics Barbara] Wincherr(ECrctronicatrySigned) (signature) District Number 5754 Place Fort Ann, 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 I(3 1ti1 Place of Disposition L 2 1 (address) W CC CC (section) pumber) /grave number/ 8Name of Sexton or Person in C e of Premises , " Z /please 4t) W Signature Title iw�wFilt DOH-1555(07/18)p 1 of 2 1 Public Health Law Sec. 4145(2b) Receipt Human remains of ' ' delivered on , 20 • Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#