Marcotte, Jean L .". , .. * It Li Ii0
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Last Sex
Name First Middle Male
Jean M Marcotte •
Date of Death Age If Veteran of U.S.Armel:Forces,
06/16/2022 93 Years War or Dates
f" Place of Death Hospital,Institution or
Street Address 67 Harris Avenue,Lake Luzerne Town,New York 12846
'Z city,Town or Village Lake Luzeme Town Undetermined ❑Pending
0 Manner of Death Natural Cause Accident Homicide Suicide ❑Circumstances Investigation
W
U Title
W Medical Certifier Name DO
0 Marena Euashachai
Address
100 Park St,Glens Falls,New Irk 12801 e ister Number
Death Certificate Filed Town Of Lake Luzerne District Number Register
City,Town or Village
5656 12
laBurial Date Cemetery,Crematory or Facility Name
06121/2022 Pineview Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
Date Place Removed
❑Removal and/or Held
F� and/or Address
N Hold
0 Point of
N�Transportation Date Shipment
Q by Common
Carrier Destination
Date Cemetery Address
Disinterment
Date Cemetery Address
ElReinterment
Permit Issued to Registration Number
Name of Funeral Home
Densmore Funeral Home Inc 00448
Address
7 Sherman Ave,Corinth,New York 12822
Name of Funeral Firm Making Disposition or to Whom
— Remains are Shipped,If Other than Above
2 Address
CC
W
C' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/17/2022 Registrar of Vital Statistics Cynthia Sherwood(Electronically Signed)
(signature)
District Number 5656 Place Town Of Lake Luzeme
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
Z Date of Disposition 412,1 I t1 Place of Disposition " 'SDAL
W (address)
W
CO (section) (lot number) il (grave number)
ft SO 11
Name of Sexton or Person in Charge of Premises (pi —seprint)
__________,/
Z �`
ill Signature Title . �i w
DOH-1555 Io7/]8)plot 2
0o_600
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#