Wildey Jr., Herbert NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
{ Name First Middle - Last Sex
Herbert Frederick Wildey Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
it`= October 21, 2011 77 War or Dates Korea
— Place of Death Hospital, Institution or
W. City, Town or Village Hudson Falls Street Address 14 Kvale Lane
Manner of Death Natural Cause 0 Accident 0 Homicide 0 Suicide nUndetermined El Pending
LU Circumstances Investigation
0
W Medical Certifier Name Title
C h 4SLQw1c.7 ✓240
Address F Y avu) J /
-i- 6 Gefra v 16 , '
Death Certificate Filed District Number Register umber
City, Town i a e ,t 5�'7 v2, 4,
®Burial ate Cemetery or Crematory
October 27, 2011 Pine View Cemetery
. ❑Entombment Address
:OCremation Quaker Rd. Queensbury,NY 12804
Date Place Removed
Removal and/or Held
and/or Address
E Hold Pine View Cemetery
f`) Date Point of
eL0 Transportation Shipment
CO by Common Destination
In Carrier
Disinterment Date Cemetery Address
10 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
Name of Funeral Firm Making Disposition or to Whom
J-- Remains are Shipped, If Other than Above
2 Address
IX
Ui
L1 Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued /6 -.2(/- +/I Registrar of Vital Statistics o� --��• 411 -
(signature)District Number S-.7zie Place tiled .2..� V
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 1 0/2 7/1 1 Place of Disposition Pine View Cemetery
2 (address)
il! Mohican 45C 1
', (section) (lot number) (grave number)
0 Name of Sexton or Perso in Charge of Premises Michael Genier
t (please print)
ill Signature 1 J-' Title Superintendent
(over)
DOH-1555 (02/2004)