Conlon, William c 0 2-
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section ice; Burial - Transit Permit
.A• z' Name First Middle Last Sex
William W. Conlon Male
Date of Death Age If Veteran of U.S. Armed Forces
April 2,2017 70 War or Dates Vietnam
r„ Place of Death Hospital, Institution or
Z.', City, Town or Village Glens Falls Street Address Glens Falls Hospital
@, Manner of Death X Natural Cause I (Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
MD
Address
GFH,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
• City, Town or Village Glens Falls 5601 2 0 3
❑Burial Date Cemetery or Crematory
April 5, 2017 Pine View Crematory
❑Entombment Address
CI Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
2 and/or Address
E- Hold
V)
O Date Point of
Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
• Permit Issued to Registration Number
• Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
3809 Main Street, Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
Es Remains are Shipped, If Other than Above
2 Address
W
Permission is hereby granted to dispose of the human remains described above as indicated.
• Date Issued ( (W I t 7 Registrar of Vital Statistics Wekil — - U11/444
(signature)
District Number 56601 Place City of Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
�r
W• Date of Disposition / SII� Place of Disposition 1nf loud Gr.reAttoc --
W (address)
co
(section) lot number) ( (grave number)
cp Name of Sexton or Person in Charge of Premises 1A, _
Z (pi se print)
W
Signature e, Title (Re MAW.
(over)
DOH-1555 (02/2004)