Sexton, Hollis NEW YORK STATE DEPARTMENT OF HEALTH .z 5 /1
Vital Records Section _ Burial - Transit Permit
Name First Middle Last Sex
Hollis Stewart Sexton Male
Date of Death Age If Veteran of U.S. Armed Forces,
F December 22, 2006 85 War or Dates WW1 -p-KJrt{i
2 Place of Death Hospital, Institution or
W City, Town, or Village Moreau Street AddressResidence
0 Manner of Death n Natural Cause ❑ Accident ❑ Homicide ❑Suicide n Undetermined ❑ Pending
W Circumstances Investigation
0 Medical Certifier Name Title
W MARK HOFFMAN MD
a Address
420 Glen St., Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
tX City, Town or Village Moreau
Date Cemetery or Crematory
❑ Burial December 26, 2006 Pine View Crematorium
Address
❑X Cremation Ouaker Road OueensburV, NY 12804-
Date ' Place Removed
0 ❑ Removal and/or Held
and/or Address
le Hold
0 Date Point of
0 ❑Transportation Shipment
O. by Common Destination
0 Carrier
Date Cemetery Address
a ❑ Disinterment
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00283
Address
H 68 Main St., P. O. Box 67, Hudson Falls, New York 12839
Name of Funeral Firm Making Disposition or to Whom
ce Remains are Shipped, If Other than Above ,
w Address
0.
Permission is hereby granted to dispose of the human rem ns described ab ve as indicated.
Date Issued /,9 b74 o? .k-�r- t oe6, Registrar of Vital Statistics t
(signature)
District Number l 6tp,2.' Place Moreau,New York
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z ^
w Date of Disposition i /2 yioi, Place of Disposition fi /oo v hw CCU, 4 Gr;wk
w (address)
0
0 0 (section) , (lot number) (grave number)
Name of Sexton or Person in Charge of Premises < , 5 C°y ri.P( -
Z ) (please print)
w
Signature U,�„ Title Cce41,ct+c,r`