Koopmann, William 1
NEW YOFK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
William Koopmann Male
fi Date of Death Age If Veteran of U.S.Armed Forces,
November 7, 2013 60 War or Dates
I-- Place of Death Hospital, Institution or
a, City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death 0 Natural Cause El Accident ID Homicide 0Suicide 0 Undetermined El Pending
Circumstances Investigation
l` Medical Certifier Name Title
Mark Hoffman MD,
Address
J. 420 Glen St. Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village 5601 4-la
®Burial Date Cemetery or Crematory
November 15, 2013 Pine View Cemetery
El Entombment Address
'0Cremation Quaker Rd. Queensbury,NY 12804
Date Place Removed
Removal and/or Held
and/or Address
_ Hold Pine View Cemetery
Date Point of
j2. Li Transportation p Shipment
10 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc.
if Address 00281
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
- Address
fC;
W'
�` Permission is her by ranted to dispose of the human r ains cribed a ve as indi«:ted.
Date Issued Registrar of Vital Statistics
// (signore)
District Number 5601 Place 0, p,,, /---6-; 42,4
,^-' I certify that the remai of the decedent identified abov re disposed of' accordance with is permit on:
Z, Disposition�W Date of P osition
4y /5 so/3 Place of Disposition / rl,G Y t� -/LA..,
2
W a A__ x rc /
(4.:.
ir°: (seattpn) lot number) (grave number)
Ci Name of :-` ,n or Person i rge of Premises L---/OP-A i e, 4• ,
(please print)
W' Sign- in.h.r1 g. fe Titl
(over)
DOH-1555 (02/2004)