Lescault, Clement Omer Jr. ... S50
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Clement Omer Lescault Jr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
07/11/2022 58 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Johnsburg Town Street Address 1394 S Johnsburg Road,Johnsburg Town,New York 12843
LIJ
p Manner of Death 0 Natural Cause Accident 0 Homicide Suicide Undetermined ❑Pending
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0 Circumstances Investigation
WMedical Certifier Name Title
CI Ellen Deprey PA
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Town Of Johnsburg District Number Register Number
City,Town or Village 5655 17
EBurial Date Cemetery,Crematory or Facility Name
07/13/2022 Pine View Crematorium
Entombment Address
Cremation Queensbury Town,New York
Donation
0 El Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
O. Date Point of
N)❑Transportation
p by Common Shipment
Carrier Destination
E
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Barton-Mcdermott Funeral Home Inc 00141
Address
9 Pine St,Chestertown,New York 12817
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
a Address
CC
W
0-
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/12/2022 Registrar of Vital Statistics jean M Comstock(E(ectronicalry Signed)
(signature)
District Number 5655 Place Town Of Johnsburg
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F—
Z Date of Disposition 1 lig 1 ZZ Place of Disposition P,,,tur,�, .J'{-o.__•
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2 (address)
ILLI
Cl)
CC (section) (lot number) (grave number)
gName of Sexton or Person in Charge of Pre .ses n‘ L 4ti
Z (p4'ase print)
W Signature Title (pm c
DOH-1555(07/18)p 1 of 2
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Public Health Law Sec. 4145(2b)
Receipt
• ,
Human remains of . .. delivered on , 20
•
Pine View Cemetery Representing the funeral home named cm burial-perm
Official Funeral Directors Reg.or License#