Gates, James P ,.... .. . ii.,5t,c.,
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
James P.Gates Male
Date of Death Age If Veteran of U.S.Armed Forces,
06/17/2022 66 Years War or Dates
F— Place of Death Hospital,Institution or
Z City,Town or Village Hudson Falls Village Street Address 19 Beach Street, Hudson Falls Village, New York 12839
W
p Manner of Death El Natural Cause []Accident Homicide []Suicide Undetermined ❑Pending
WI
U Circumstances Investigation
Wp Medical Certifier Name Title
Donald Merrihew MD
Address
319 Bay Road,Queensbury Town,New York 12804
Death Certificate Filed Village Of Hudson Falls District Number Register Number
City,Town or Village 5726 31
Burial Date Cemetery,Crematory or Facility Name
O6/22/2022 Pine View Crematorium
Entombment Address
[]Cremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
f- Hold Address
U)
0
O. Date Point of
Cl) Transportation
p by Common Shipment
Carrier Destination
[]Disinterment Date Cemetery Address
Date Cemetery Address
pi Reinterment
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
E- Remains are Shipped,If Other than Above
Address
CC
Q. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/21/2022 Registrar of Vital Statistics Cynthia Bar�fin(Electronically Signed)
(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:
W~ (�
Date of Disposition �_Z Z-ZO�L Place of Disposition i �e (Ji �'� CPi/v �p
2 (address)
W
Cl) O (section) Cj (lot number) (grave number)
0 Name of Sexton or Person in Charge of remis Kok/rtic,J'b O�
(please" print)
Z
W Signature Title pf,Q�`d
DOH-1555(o7/18)p 1 of 2
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# •