Tabor, Donald NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
..; Donald Vincent Tabor Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 11, 2012 85 War or Dates
I"- Place of Death Hospital, Institution or
WCity, Town or Village Glens Falls Street Address The Pines
13 Manner of Death Natural Cause 0 Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
Suzanne M. Rayeski, M.D
Address
170 Warren Street Glens Falls, NY 12801
Death Certificate Filed District Number 5�0\ Register,(V. er
City, Town or Village L.��
®Burial Date Cemetery or Crematory
October 15, 2012 MT. HERMON CEMETERY
❑Entombment Address
❑Cremation
Date Place Removed
zElRemoval and/or Held
0 and/or Address
p Hold MT. HERMON CEMETERY
GO Date Point of
aD Transportation Shipment
CO by Common Destination
in Carrier
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
I— Remains are Shipped, If Other than Above
2 Address
Et
LU
Ct' Permission is hereb granted to dispose of the human remains descr' ed a�ov s in
Date Issued /fJ f 20/2— Registrar of Vital Statistics p t r
(signature)
District Number S&Q/ Place �p/ , A- A /�X
1--
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 1 0/1 5/1 2Place of Disposition Mt. Harms n CPni tery
2, (address)
Wi Family Plot
CO
(section) (lot number) (grave number)
C Name of Sexton or Person in rge of Premises Michael Genier
n (please print)
' Superintendent
Ui Signature �'� Title
(over)
DOH-1555 (02/2004)