Loading...
Duvall II, Andre g' NEW YORK STATE DEPARTMENT OF HEALTH tt r1't~'3" I Vital Records Section . .- 1 Burial - Transit Permit Name First Middle Last Sex Andre Edmond Duval II Male Date of Death Age If Veteran of U.S. Armed Forces, ); February 17, 2017 54 War or Dates z. Place of Death,,E Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide D Suicide ❑ Undetermined ❑ Pending U Circumstances Investigation W Medical Certifier Name Title Matthew Anderson, Dr. Address -! 17 Baywood Dr. #1 Queensbury, NY 12804 Death Certificate Filed District Number Register NSim er City, Town or Village l /©C ❑Burial Date Cemetery or Crematory February 21, 2017 Pine Vew Crematorium ❑Entombment Address -.'®Cremation Queensbury,NY 12804 Date Place Removed ❑ Removal and/or Held and/or Address Hold (0, Date Point of ct. El Transportation Shipment CO' by Common Destination 0 Carrier ❑ Disinterment Date Cemetery Address ❑ Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home, Inc. 00281 Address Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839 1 Name of Funeral Firm Making Disposition or to Whom -- Remains are Shipped, If Other than Above. '. Address Permission is hereby granted to dispose of the human remains described above as indicated. ' Date Issued 2 /z ( (('7 Registrar of Vital Statistics CL (signature District Number S G v I Place 6 C�v's �\ S 1 • I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: w Date of Disposition 02/21/2017 Place of Disposition Queensbury,NY 12804 2, (address) W FE (section) / (lot number) c (grave number) 0' Name of Sexton or Person in Charge of Pr mises L if:sf —)srnla a (pl ase print) Signature ( 1h Title (tEsvApit (over) . DOH-1555 (02/2004)