Vincent, William r 4
IZ
NEW YORK STATE DEPARTMENT OF HEALTH 4% 4t
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
William John Vincent Male ID
Date of Death Age If Veteran of U.S.Armed Forces,
December 30,2017 73 War or Dates
Place of Death Hospital, Institution or
t>tJ° City, Town or Village city of Glens Falls Street Address Glens Falls Hospital
0 Manner of Death®Natural Cause 0 Accident 0 Homicide ❑Suicide El❑Undetermined ❑Pending
ILI Circumstances Investigation
wMedical Certifier Name Title
tA Dr.Amy Hogan Moulton MD
Address
„E` Broad Street Plaza,Glens Falls,NY 12801
E= Death Certificate Filed District Number Register Number
Ci `ty, Town or Village Glens Falls, 5601 0 I (sjr
Burial Date Cemetery or Crematory
January 02,2018 Pine View Crematorium
❑Entombment4,7 Address
_'®Cremation Quaker Road,Queensbury,NY 12804
Date Place Removed
Z❑Removal and/or Held
and/or Address
rZ
rZ Hold
Date Point of
012 Q Transportation Shipment
$ by Common Destination
,,;. Carrier
,
Date CemeteryAddress
El Disinterment
❑Renterment Date Cemetery Address
Permit Issued to Registration Number
• Name of Funeral Home Carleton Funeral Home,Inc. 00281
• Address
68 Main Street,PO Box 67,Hudson Falls,NY 12839
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
1
it Permission is hereby granted to dispose of the human remains described above as indicated.
fl Date Issued f /2-1 20 (g, Registrar of Vital Statistics WCAA4'v—Q, k.A..)
(signature
District Number 5601 Place 6 u.,v,-s ,\\.) lv
4• 3 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
14 e �i Pmr.-
Date of Disposition I jy�l $ Place of Disposition ,a ,,,,,i
i (address)
tet
(section) (lot number) (grave number)
• Name of Sexton or Person in Charge of Pre isesI , S"'^4�
/i (pl se print)
• Signature �" Title l 14,1t Nn—
(over)
DOH-1555 (02/2004)