Cloutier, Herbert NEW YORK STATE DEPARTMENT OF HEALTH l ` 1 # sts
Vital Records Section Burial - Transit Permit
ti Name First Middle Last Sex
Herbert LaForest Cloutier Male
I, Date of Death Age If Veteran of U.S. Armed Forces,
July 12, 2018 72 War or Dates
IN Place of Death Hospital, Institution or
City, Town or Village Hudson Falls Street Address 41 John Street
', Manner of Death 0 Natural Cause Accident Homicide Suicide Undetermined Pending
�g Circumstances Investigation
i11.. Medical Certifier Name Title
Michael Sikirica MD,
Address
50 Broad Street Waterford, NY 12188
Death Certificate Filed District Number Register Number
City, Town or Village 51 2.4, /�
❑Burial Date Cemetery or Crematory
N _= July 13, 2018 Pine Vew Crematorium
❑Entombment Address
®Cremation Queensbury,NY 12804
Date Place Removed
Removal and/or Held
and/or Address
Hold
Xtt. Date Point of
❑Transportation Shipment
fl by Common Destination
Carrier
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
,,3. 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' Remains are Shipped, If Other than Above
Address
lc
Permission is hereby granted to dispose of the human remains ascribed above as indicated.
Date Issued `7-/B - t Registrar of Vital Statistics """ oj e c -Q� i_.--0-._
g,, 111SSS
- (signature)
District Number__ '71_ Place �, ( � S�„� to Oct _
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
iii Date of Disposition 07/13/2018 Place of Disposition Queensbury,NY 12804
2 (address)
(section) P
I t number)
Name of Sexton or Perso in Charge of Premises td4 L S (grave number)
(plebse print)
Signature4-- Title t(rl"ir1
(over)
DOH-1555(02/2004)