Valyer Sr., Lester - S. 11 10
NEW YORK STATE DEPARTMENT OF HEALTH p� T
Vital Records Section ,,p Burial - Transit Permit
Name First Middle Last Sex
Lester Fredrick Valyer Sr.
Male
Date of Death Age ". If Veteran of U.S. Armed Forces,
11/01/2018 88 Years War or Dates
• Place of Death Hospital, Institution or
Lti City, Town or Village Granville Viliage Street Address Indian River Rehabilitation And Nursing Center
W Manner of Death El NaturalCause El Accident ❑Homicide El Suicide ❑Undetermined ❑Pending
Circumstances Investigation
W Medical Certifier Name Title
ta Thomas Kandora MD
Address
17 Madison St.Granville Village, New York 12832
Death Certificate Filed District Number Register Number
,` City, Town or Village Granville Village 5725 45
t ❑Burial Date Cemetery or Crematory
11/02/2018❑Entombment 11/02/2018 Pine View Crematorium
Address
Cremation Queensbury Town, New York
Date Place Removed
❑Removal and/or Held
10- and/or Address
Hold
mi
1.4 Date Point of
❑Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
1 Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
't Address
68 Main Stpo Box 67,Hudson Falls.New York 12839
- Name of Funeral Firm Making Disposition or to Whom
t Remains are Shipped, If Other than Above
2 Address
Itt
LLI
u.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11t0212018 Registrar of Vital Statistics xirfirrdRoberts!E :ctmrvnrc4liySignea
, ', (signature)
District Number 5725 Place Granville Village, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tii Date of Disposition ill 7 1 i 8 Place of Disposition fj /
(address)
LO
U.'., (section) (1 numbert (grave number)
CCU Name of Sexton or Person in Char a of Premises /r"toL 31,4r
zm (pleas print)
kU
Signature Title nii-" I`""
(over)
DOH-1555 (02/2004)