Seelye, Marshall NEW YORK STATE DEPARTMENT OF HEALTH
Vit4.I Records Section Burial - Transit Permit
Name First Middle Last Sex
Marshall Browne Seelye Male
Date of Death Age If Veteran of U.S. Armed Forces,
April 2, 2018 91 War or Dates
F Place of Death Hospital, Institution or
u CCity, Town or Village Granville Street Address Slate Valley Center for Rehab and Nursing
W; Manner of Death❑ Natural Cause ❑ Accident ❑ Homicide 0 Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
WW` Medical Certifier Name e ) 4 itA0 1- f �M i�itle
Address Y
Dea s .*.ificate Filed 6 (1 District Number Register Number
Cit TovQn or Village �`� �/ 5-15(v sS
®Burial Date Cemetery or Crematory
April 9, 2018 Pine View Cemetery
❑Entombment Address
❑Cremation Quaker Rd. Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
O and/or Address
rz Hold Pine View Cemetery
Date Point of
❑Transportation Shipment
CO by Common Destination
a Carrier
❑ Disinterment Date Cemetery Address
Date Cemetery Address
El Reinterment
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
M Address
CC-
W°
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued o 4 Registrar of Vital Statistics r::��..��✓✓�u..�� pQQy�,`os laol�
(signature)
District Number 51 .b Place -Thu* p ' 6'( 4JILuE
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W'. Date of Disposition 04/09/2018 Place of Disposition Quaker Rd. Queensbury,NY 12804
M (address)
W Hudson#1, Lot
co
ce ction) (lot number) (grave number)
t Name of Se on or Person in Charge of Premises 4)m1-�� r-b(-)h i
� (Plea a print)
Z cI
W Signature Kilts .-, A. Titl iU o-��f12...r----'
(over)
DOH-1555 (02/2004)