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Dodge, John Wesley - _ � Wo NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex John Wesley Dodge Male Date of Death Age If Veteran of U.S.Armed Forces, 05/07/2020 74 Years War or Dates 1965-1971 F Place of Death Hospital,Institution or WCity,Town or Village Hartford Town Street Address 282 Dick Hill Road,Hartford Town,New York 12838 p Mannerof Death ©Natural Cause Accident Homicide Suicide Undetermined Pending W Circumstances Investigation U Title W Medical Certifier Name Charles Yun MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Hartford 5759 9 ❑Burial Date Cemetery,Crematory or Facility Name 05/12/2020 Pine View Crematorium Entombment Address rKCremation Queensbury Town,New York Donation Z Removal Date Place Removed O and/or and/or Held ~N Hold Address dDate Point of N ❑Transportation Shipment p by Common Carrier Destination Disinterment Date Cemetery Address ent Rei_ntermDate Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carieton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition orto Whom F_ Remains are Shipped,If Other than Above Address Q W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/12/2020 Registrar of Vital Statistics (Denise Petteys(ECectronicalTy Signed (signature) District Number 5759 Place Hartford, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition S(f 1v Place of Disposition 1L (address) 2 W N (section) (lot numb', (grave number) cc C1 'S"f 8 Name of Sexton or Person in Chargez7yx-- - mi //ease print) W Signature Title DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 11a 3803 Receipt Human remains of»- delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#