Yates, James Henry # 13
NEW YORKSTATE DEPARTMENT OF HEALTH � Burial - Transit Perm
Bureau of Vital Records
Name First Middle Last Sex
James Henry Yates Male
Date of Death Age If Veteran of U.S.Armed Forces,
11/19/2022 80 Years War or Dates 1963-1969
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address 13 Terra Cotta Avenue,Glens Falls, New York 12801
W Manner of DeathEi g
0 �NaturalCause ❑Accident Homicide Suicide Undetermined �Pendin
W Circumstances Investigation
11UA Medical Certifier Name Title
CI Antonio Izzo NP
Address
340A Main Street,Hudson Falls Village,New York 12839
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 586
Burial Date Cemetery,Crematory or Facility Name
11/28/2022 Pine View Crematorium
Entombment— Address
EICremation Queensbury Town,New York
[]Donation
Z❑Removal Date Place Removed
and/or and/or Held
~ Hold Address
N
0
IL Date Point of
N❑Transportation Shipment
p by Common
Carrier Destination
O
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
1— Remains are Shipped,If Other than Above
■5 Address
CC
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/23/2022 Registrar of Vital Statistics Megan.Wo(in(ECectronica1tySigned)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
t` If4
W Date of Disposition I i i 7q 171 Place of Disposition address)
W
CC CC l//Jit(section) /7 c
/!ot number) (grave number)
0 ::::: °'
or Person in Charge of Pre ' ee Title
DOH-1555(07/18)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 Ipurial permit
Official Funeral Directors Reg.or License#