White, William NEW YORK STATE DEPARTMENT OF HEALTH 4 6 (9
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
William Albert Whit' Male
Date of Death Age If Vet ran of U.S. Armed Forces,
Aug 24, 2017 60 War or Dates -0-
- Place of Death Hospital, Institution or
ZCity, Town or Village Fort Ann, NY Street Address 72 East Farmwood RD
O Manner of Death❑Natural Cause ❑Accident ❑Homicide ❑Suicide r-i❑Undetermined ❑Pending
LiSS pp,, Circumstances Investigation
Medicarterti#ierJeav Name Title
C
Albany, NY Address
Deapi Ccrti,cate Filed . District Number Register Nu er
CitI_g sat Village �s-rL� � 75 d
❑Burial Date Aug 29, 2017 Cemetery or Cren inf View Crematorium
['Entombment Address Queensbury,remation
0 , Date Place Removed
❑Removal and/or Held
and/or I* Address
Hold
filet
6. Date Point of IL in LiTransportation Shipment
O by Common Destination
Carrier '
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carl eton Funeral Home, Tnc
Addregikidson Falls. lPgY
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
,2 Address
Cr
to
A' Permission is hereby granted to dispose of the human rema' s described above a incl. ted.
Date Issued S ` ,5 y- Registrar of Vital Statistics ,..7% .,_,,, •t.-ILA..JZ-
( ig ure
District Number .57 3 y- Place gipty--lx_rt / e Z -
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
111• Date of Disposition I I I 1 'lace of Disposition f,u0b,,, ,,,,,,,440,—
1 (address)
U
CC (section) (lot number (grave number)
0 Name of Sexton or Person in Charge of Premises L fr., J►'+41#
/J (p ase print)
Signature Y&. Title PE Pi
(over)
DOH-1555 (02/2004)