Traver, William 000 y
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section
Burial - Transit Permit
Name First Middle z_ Last Sex
William Irving Traver Male
Date of Death Age If Vet�iin of U.S. Armed Forces,
F January 9, 2006 70 War or Dates
Z Place of Death Hospital, Institution or
W City, Town, or Village Fort Edward Street Address8 Bridge Street
0 Manner of Death x❑ Natural Cause ❑ Accident ❑ Homicide ❑Suicide ❑ Undetermined ❑ Pending
W Circumstances Investigation
J Medical Certifier Name Title
W Philip Gara, MD Dr.
d Address
Broadway, Fort Edward, NY 12828
Death Certificate Filed District~Num e Re ter Number
City, Town or Village Fort Edward ( 1 2
Date Cemetery or Crematory
❑ Burial January 12, 2006 Pine View Crematorium
Address
❑X Cremation Ouaker Road Oueensburv, NY 12804-
Date Place Removed
0 ❑ Removal and/or Held
- and/or Address
Hold
0 Date Point of
0 ❑Transportation Shipment
C. by Common Destination
A Carrier
Date Cemetery Address
a ❑ Disinterment
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00284
Address
H 68 Main St., P. 0. Box 67, Hudson Falls, New York 12839
Name of Funeral Firm Making Disposition or to Whom
a Remains are Shipped, If Other than Above
w Address
O.
Permission is her b ranted to dispose of the human re ' s described bove as i dicated.
Date Issued �fQ Registrar of Vital Statistic
(signatu e) 211
4/4D
District Number 79 V Place Fort Edward,New York
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition Place of Disposition
2 (address)
W
v)
re (section) (lot number) (grave number)
0
O Name of Sexton or Person in Charge of Premises
2 (please print)
W
Signature Title