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O'Connor, Francis NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit iiiiiiiii Name First Middle Last Sex Francis Scott O'Connor Male €' Date of Death Age If Veteran of U.S. Armed Forces, di July 26, 1996 76 War or Dates Place of Death Hospital, Institution or City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home el Manner of Death©Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending Circumstances Investigation 2 Medical Certifier Name Title 1 Thomas F. Kandora MD Address 7240 Upper Broadway, Ft. Edward, N.Y. 12828 ;' Death Certificate Filed Fort Eduard District Nun rnin5 Register Number i iii City, Town or Village '0) ,—�! Date Cemetery or Crematory Burial July 30, 1996 Pine View Cemetery Address ❑Cremation Tn of Queensburv, NY FDate Place Removed 0 ❑Removal and/or Held �- and/or Address TAHold Q Date Point of %❑Transportation Shipment G by Common Destination Carrier ❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number iig Name of Funeral Home Carleton Funeral Home Inc. 00310 Address iiiil P.O. Box 67, 68 Main St., Hudson Falls, N.Y. 12839 r Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above 0 Address IAA 1 N;i Permission is hereby granted to dispose of the human rem4itys descd bove as indicated. €>l Date Issued 75 h� Registrar of Vital Sta'tcs _44!/ -1!/i - �-4-4-.,- $ignature)./ 5755 Place Fort Edward; NY District Number I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: il Date of Disposition 7/30/96 Place of Disposition Pine Vi ew cemetery, Queenc bury, NY (address) W Mohawk 107-B 1 U C (section) (lot number) (grave number) GName of Sexton or Person in Charge of Premises Michael Lope z g (please print) W Signature Title Working Foreman DOH-1555 (10/89) p. 1 of 2 VS-61