Walsh, Courtney Jan 20 17 06:21 p Parker Bros. Memorial / . "''` 5182731029 f� Q
p.1
NEW YORK STATE DEPARTMENT OF HEALTH 7T 6 "
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Courtney David Walsh Male
Date of Death Age If Veteran of U.S.Armed Forces,
E? 01/17/2017 72 War or Dates No
ii Place of Death Hospital, Institution or
City,Town or Village City of Albany Street Address Albany Medical Center
`p Manner of Death®Natural Cause Accident El Homicide ❑Suicide �Undetermined ❑Pending
Circumstances Investigation
to Medical Certifier Name Title
i Chaddy Elhawary, MD
Address
43 New Scotland Avenue Albany, NY 12208
ia Death Certificate Filed District Number Register Nu her
'i City, Town.or Village City of Albany 101 • )
': ❑Burial Date Cemetery or Crematory
O1/23/2017 • Pine View Crematorium
❑Entombment Address
A' ❑x Cremation Queensbury, NY
Date Place Removed .
Z Removal and/or Held
t ❑
and/or Address•
EZ, Hold •
1.4
0 ' Date Point of
Transportation Shipment
a by Common Destination
Carrier
❑Disinterment ' Date Cemetery Address
❑Reinterment
Date Cemetery Address
ys
'E Permit Issued to Registration Number
%> Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
68 Main St, PO Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
i
` Permission is hereby granted to dispose of the human remains described a ye as indicated.
,d1ft` Date Issued �1 Re istrar of Vital Statistics �.
(signature
District Number Place )
I certify that the remains of the decedent identifie a e were disposed of i cor a with this permit on:
lti Date of Disposition 1/21 in Place of Disposition (IX Or.--, (-Mrs et it u A...-
(address)
ILI
tr (section) //(lot number) � (grave number)
flName of Sexton or Person in Charge of-Premises (L`K J e.1t 1r
2 /1/ (ease print)
Signature 4 C „), Title CR-E no ion
(over)
DOH-1555 (02/2004)