Carboy, William NEW YORK STATE DEPARTMENT OF HEALTH #46
Vital Records Section Burial - Transit Permit
Name First Middle Last 1 Sex
William Thomas Carboy I Male
Date of Death I Age I If Veteran of U.S.Armed Forces,
09/16/2017 1 73 War or Dates
Z Place of Death Hospital, Institution or
City,Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause 0 Accident El Homicide❑ Suicide Undetermined El Pending
iiii
Circumstances Investigation
Medical Certifier Name Title
PAUL BACHMAN,
Address
i ' 3767 Main ST. Warrensbur• NY 12885
Death Certificate Filed District Number Register Number
�, City,Town or Village
y�c'❑Burial Date or rematory /�
09/18/2017 1 lO,iY e cxe .A;/ /
❑Entombment Address /
®Cremation (��G/ c �.- ' / �1� �C)i/—�.� Jl��
Date Place Removed ,
:74 ri Removal and/or Held
and/or Address
Hold
_:-A Date Point of
Transportation Shipment
by Common Destination
tei Carrier
❑ Disinterment Date Cemetery Address
Reinterment
II
Date Cemetery Address
r
Permit Issued to Registration Number
Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00141
LAX
Address
9 Pine St/P.O. Box 455 Chestertown NY 12817
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
s Permission is hereby granted to dispose of the human remains described above
bove as indicated.
Datel. Issued cf i 1 Si 2f7 I`7 Registrar of Vital Statistics `,r` CAA. r " .,
':�f (signature)
District Number S 60 I Place 6 Cvv\.$ 1 S N✓�'
i
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition Q/Ii Ili Place of Disposition ffra-/ c,{G,—/
(address)
(section) A (l t number (grave number)
' _ Name of Sexton or Person in Charge of Premises t 0L :iM
(please print)
)
r Signature it %AI Title f`-P in
(over)
DOH-1555(02/2004)