Weaver, John h /1 3S oil
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit 1SI'� P rmit
Vital Records Section
Name First Middle Last Sex
John Joseph Weaver Male
Date of Death Age If Veteran of U.S. Armed Forces,
05112/2018 69 Years War or Dates 1968-1969
' Place of Death Hospital, Institution or
1 City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death E Natural Cause El Accident ❑Homicide ❑Suicide ❑Undetermined Pending
IN
Circumstances Investigation
w• Medical Certifier Name Title
0 Suzanne Bergin DO
E ;e
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
' City, Town or Village Glens Falls 5601 231
0 Burial Date Cemetery or Crematory
05/14/2018 Pine View Crematorium
,,.,❑Entombment Address
Cremation Queensbury Town, New York
Date
Place Removed
Removal and/or Held
and/or
i r.„
;``
iAddress
Hold
Date Point of
Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
R"; ❑Reinterment
1 Date Cemetery Address
',
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address
AI;i 68 Main Stpo Box 67,Hudson Falls,New York 12839
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
t-2 Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05,14/2018 Registrar of Vital Statistics Robert_t Curtis r'E[:etronically Aiwa)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition VIsi a Place of Disposition cf,�, es,it,
2 (address)
Cr (section) iii(lot number) (grave number)
pName of Sexton or Person in Char of Premises `1c,t,k. 3'-.414
(pltvase print)
WI
Signature -r Title filifiAt(p2
(over)
DOH-1555 (02/2004)