Crandall, Daneil NEW YORK STATE DEPARTMENT OF HEALTH 4. "t y
Vital Records Section Burial - Transit Perm
Name First Middle Last Sex
Daniel Schuyler Crandall Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 29, 2018 75 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address 26 Flandreux Ave
13 Manner of Death 0 Natural Cause Accident ❑ Homicide ❑ Suicide El Undetermined Pending
L1JCircumstances Investigation
W Medical Certifier Name Title
CI John Stoutenberg MD, M.D. Dr.
Address
102 Park St. Glens Falls, NY 12801
Death Certificate Filed District Number RegisterNumber
City, Town or Village _ 5 b 0 i 5 r3
❑Burial Date Cemetery or Crematory
November 30, 2018 Pine Vew Crematorium
M '.❑Entombmentit Address
®Cremation Quaker Road Queensbury,NY 12804
',CO, Date Place Removed
z ❑ Removal and/or Held
and/or Address
.' Hold Pine View Crematorium
Date Point of
p" 0 Transportation Shipment
by Common Destination
0 Carrier
;, Disinterment Date Cemetery Address
I: Reinterment
Date Cemetery Address
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
1.4 Remains are Shipped, If Other than Above
Address
iiq
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued )\ t '3 olice Registrar of Vital Statistics ,A.)
(sign ure)
District Number J b0) Place 6 lsz-Ar., s WO,.\\S iv y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 11/30/2018 Place of Disposition Quaker Road Queensbury,NY 12804
W (address)
Co
r: (section) of number) ,\ (grave number)
0 Name of Sexton or Person in Charge of Pr mises .t L. triAtlit
z (plelse print)
Signature Title 46011
(over)
DOH-1555 (02/2004)