Bly, Walter NEW YORK STATE DEPARTMENT OF HEALTH
Vita Records Section Burial - Transit Permit
Name First Middle Last Sex
Walter Floyd Bly Male
Date of Death Age If Veteran of U.S. Armed Forces,
July 18, 2011 80 War or Dates Korea
IPlace of Death Hospital, Institution or
w City, Town or Village Hudson Falls Street Address 28 North Oak Street
WManner of Death u Natural Cause ❑ Accident ❑ Homicide ElSuicide ❑ Undetermined ❑ Pending
U Circumstances Investigation
W Medical Certifier Name Title
CI John Stoutenberg MD, M.D. Dr.
Address
102 Park St. Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village 5 7,2(o j
®Burial Date Cemetery or Crematory
July 22, 2011 Pine View Cemetery
?❑Entombment Address
['Cremation Quaker Rd. Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
p' Hold Pine View Cemetery
CO Date Point of
a ❑Transportation Shipment
(t) by Common Destination
0 Carrier
❑ Disinterment Date Cemetery Address
Date Cemetery Address
El Reinterment
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00276
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
- Remains are Shipped, If Other than Above
2 Address
OL
Wa.'
Permission is hereby granted to dispose of the human remains
`� _�
desscriibed above as indicated.
Date Issued ' a(/-a l--� Registrar of Vital Statistics `j`" L am`-A--t-``
(signature)
District Number S)ac, Place V :e, c o
1
I certify that the remains of the decedent identified abo e were disposed of in accordance with this permit on:
W; Date of Disposition 7/22/201klace of Disposition Pine View Cemetery
2` (address)
W' Horicon 19C 1
0)
ce (section) (lot number) (grave number)
0 Michael Genier
d' Name of Sexton or Pers n in Charge of Premises
:\1.. . frA . Superintendent)
- Signature Ate" Title
(over)
DOH-1555 (02/2004)