Gray, Stephen John # 390
NEW YORK STATE DEPARTMENT OF HEALTH Cli
Bureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
Stephen John Gray Male
Date of Death Age If Veteran of U.S.Armed Forces,
09/20/2023 63 Years War or Dates
H Place of Death Hospital,Institution or
W City,Town or Village Hudson Falls Village Street Address 22 Juckett Drive, Hudson Falls Village,New York 12839
p Manner of Death ❑� Natural Cause Accident ❑Homicide Suicide ❑Undetermined ❑Pending
W Circumstances Investigation
U
W Medical Certifier Name Title
CI Christopher Mason DO
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed Village Of Hudson Falls District Number Register Number
City,Town or Village 5726 30
riBurial Date Cemetery,Crematory or Facility Name
09/22/2023 Pine View Crematorium
Entombment Address
Cremation Queensbury Town,New York
riDonation
ZO❑Removal Date Place Removed
and/or and/or Held
F- Hold Address
N
0
d Date Point of
VI 0 Transportation
p by Common Shipment
Carrier Destination
Date Cemetery Address
nDisinterment
r Date Cemetery Address
1 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
H Remains are Shipped,If Other than Above
5 Address
CC
W
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/22/2023 Registrar of Vital Statistics Cynthia (Bardin(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:
F
Z Date of Disposition Z3 ZOZ} Place of Disposition ,J ' l Ae-t,4) C
r`tw(.,
W
2 (address)
W
NtE (section) �/ (lot number) (grave number)
0 Name of Sexton or Person in Charge of Pre ises I�a r J1/a�b „Lod
Z l / (please print)
Signature Z !.' Title t?irer
D0H-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 017310
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#