Bruce, Jacob Paul (i__ .)
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Jacob Paul Bruce Male
Date of Death Age If Veteran of U.S.Armed Forces,
06/04/2022 44 Years War or Dates
i_ Place of Death Hospital,Institution or
WCity,Town or Village Hudson Falls Village Street Address 52 Ferry Street, Hudson Falls Village, New York 12830
p Manner of Death 0 Natural Cause ❑Accident Ill Homicide Suicide Undetermined nPending
ILI
0 Circumstances f' 'Investigation
W Medical Certifier Name Title
0 Robert Lemieux Coroner
Address
415 Lower Main Street,Hudson Falls Village,New York 12839
Death Certificate Filed Village Of Hudson Falls District Number Register Number
City,Town or Village 5726 30
Burial Date Cemetery,Crematory or Facility Name
06/07/2022 Pine View Crematorium
Entombment Address
Cremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
Date Point of
d)❑Transportation Shipment
Q by Common
Carrier Destination
Disinterment
Date Cemetery Address
Date Cemetery Address
ElReinterment
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
1— Remains are Shipped,If Other than Above
a Address
Q
W
C' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/07/2022 Registrar of Vital Statistics Cynthia Bardin(E(ectronicaffySigned)
(signature)
District Number 5726 Place Village Of Hudson Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I— �i 'I
W Date of Disposition fP I"?I it Place of Disposition 4 i..
(address)
uJ
N (section) (lot number/ (grave number)
cc
Name of Sexton or Person in Charge of Premis / ease print)
z C �
W Signature Title
DOH-1555(07/18)p 1 of 2
TZ 7rl
i
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#