Stockman, Silas ,
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Silas Elmer Stockman Male
Date of Death Age If Veteran of U.S. Arme
January 30, 2016 97 War or Dates orld War II
c of Death VHospital, Institution or
City, own or Village Glens Falls Street Address Glens Falls Hospital
O nner of Death 0 Natural Cause n Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
W Circumstances Investigation
LW11 Medical Certifier Name Title
a Suzanne Rayeski, M.D. Dr.
Address
3767 Main Street Warrensburg, NY
th Certificate Filed District Number Register Number
ity, Town or Village { e r S rA_1 1 S 5601 5 7
Burial Date Cemetery or Crematory
February 4, 2016 Pine View Cemetery
❑Entombment Address
0 Cremation Quaker Rd. Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
Hold Pine View Cemetery
CO Date Point of
❑Transportation Shipment
to by Common Destination
a Carrier
Date Cemetery Address
❑ Disinterment
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
Remains are Shipped, If Other than Above
E Address
X
al
CL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 2-7 i ) I 6 Registrar of Vital Statistics W� l.0`)��-
(signature)
District Number 5601 Place (-) Cs S Fc l\S, /U `,)
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 02/04/2016 Place of Disposition Quaker Rd. Queensbury,NY 12804
(address)
WCO Sec. 34 , Lot 382 Wah—Ta—Wah 6
it (section) (lot number) (grave number)
8 Name of Sexton or Person in Charge of Premises Connie L. Goedert
(71_ /--
(please print)
W` Signature lti.c 7/C��C ��h Title Cemetery Superintendent
(over)
DOH-1555 (02/2004)