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Storlie, Wayne Sr.# 407 N EW YORK STATE DEPARTMENT OF HEALTH Bureau of Vital Records Burial - Transit Permit Name First Middle Last Sex Wayne Gary Storlie Sr. Male Date of Death Age If Veteran of U.S. Armed Forces, 09/12/2019 80 Years War or Dates 1957-1966 Place of Death Hospital, Institution or W City, Town or Village Hudson Falls Village Street Address 87 John Street, Hudson Falls Village, New York 12839 p Mannerof Death ©Natural Cause Accident Homicide Suicide Undetermined El Pending W Circumstances Investigation W Medical Certifier Name Title Charles Yun MD Address 100 Park St, Glens Falls, New York 12801 Death Certificate Filed District Number Register Number City, Town or Village Hudson Falls Village 5726 14 ❑ Burial Date Cemetery, Crematory or Facility Name 09/16/2019 Pine View Crematorium Entombment aCremation Address Queensbury Town, New York Donation 0 Removal Date Place Removed and/or and/or Held H Hold Address N O ( Date Point of Cl)Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address ❑ Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Stpo Box 67, Hudson Falls, New York 12839 Name of Funeral Firm Making Disposition orto Whom Remains are Shipped, If Other than Above Address Ir W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 09/16/2019 Registrar of Vital Statistics Cyntkia,4 Bardin (ElectronicaCCySigned) (signature) District Number 5726 Place Hudson Falls Village, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: F- Z Date of Disposition gjjj 111 Place of Disposition V.7d t-j W 2 /address/ W Cl) cc[/ (section) /J�_ Aotnumber) (grave number) 0 0 Z Name of Sexton or Person in Charge of Premises lease print � W Signature Title � DOH-1555 (07/18) p 1 of 2 Public Health Law Sec. 4145(2b) U12.535 Receipt Human remains of V�k�lrlc'�>��' delivered on a` , 20// Pine View Cemetery Representing the funeral home nam sin n permit Official Funeral Directors Reg. or License # /