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Waite, Lester NEW YORK,'3TATE DEPARTMENT OF HEALTH Burial - Transit Permit Vital Records Section Name First Middle Last Sex Lester Roland Waite Male Date of Death Age If Veteran of U.S. Armed Forces, February 17, 2014 82 War or Dates ',1'_ Place of Death Hospital, Institution or W City, Town or Village Argyle Street Address PLEASANT VALLEY NURSING FAC. Manner of Death Natural Cause ❑ Accident ElHomicide D Suicide inUndetermined ❑ Pending Circumstances Investigation W Medical Certifier Name Title O Edit Masaba, Address 35 Gibea St. Cambridge, NY 12816 Death Certificate Filed District Number Register Number City, Town or Village `7 -SO J ®Burial Date Cemetery or Crematory February 24, 2014 Pine View Cemetery ❑Entombment Address ❑Cremation Quaker Rd. Queensbury,NY 12804 , Date Place Removed z ❑ Removal and/or Held • and/or Address F Hold Pine View Cemetery 0) Date Point of Transportation Shipment 60 by Common Destination CI;' Carrier 0 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 Name of Funeral Firm Making Disposition or to Whom F- Remains are Shipped, If Other than Above 2 Address IX W; Ct' Permission is hereby granted to dispose of the human refrains described above a \indicated. _ �� ! Registrar of Vital Statistics `\!. ‘. '‘`.`�ti,X_� ,1,t - 'T <Ahk Date Issued- �� A ." (signature) District Number L j'\ , Place \( ,u. ), '\ ,c \c\1� \\ _,S2 -- . I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W: Date of Disposition 02/24/2014 Place of Disposition Quaker Rd. Queensbury,NY 12804 2 (address) W 17 B Hudson Sec. 2 6 0)ir (section) (lot number) (grave number) © Connie L. Goedert p Name of Sexton or Person in Charge of Premises z (please print) W Superintendent Signature Title (over) DOH-1555 (02/2004)