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Donnelly Jr.Jeffry Joseph Patrick 411:0Lfo NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Jeffry Joseph Patrick Donnelly Jr. Male Date of Death Age If Veteran of U.S.Armed Forces, 05/05/2023 27 Years War or Dates F. Place of Death Hospital,Institution or Z City,Town or Village Argyle Town Street Address 1284 N Coach Road,Argyle Town,New York 12809 pManner of Death 0 Natural Cause (Accident Homicide 0Suicide ri Undetermined Pending W Circumstances Investigation W Medical Certifier Name Title C3 Robert Lemieux Coroner Address 415 Lower Main Street,Hudson Falls Village,New York 12839 Death Certificate Filed Town Of Argyle District Number Register Number City,Town or Village 5750 26 Burial Date Cemetery,Crematory or Facility Name 05/09/2023 Pine View Crematorium Entombment — Address ©Cremation Queensbury Town,New York Donation Q❑Removal Date Place Removed and/or and/or Held F Hold Address dDate Point of Ch Transportation Shipment Q by Common Carrier Destination Disinterment Date Cemetery Address El 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 F Remains are Shipped,If Other than Above a Address CC LU O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/09/2023 Registrar of Vital Statistics Shelley Mckernon(E(ectronical(y Signed) (signature) District Number 5750 Place Town Of Argyle I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition ShD`'j3 Place of Disposition ?iv,IL- LLI 2 (address) W CD CC (section) (lot number) (grave number) g Name of Sexton or Person in Charge o emises / " Lltt tease print) Z W Signature Title (( 'N1r4t' 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 burial permit Official Funeral Directors Reg.or License#