Loading...
Summerville, Dale �-s " 'Izl NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex i Dale Allen Summerville Male ji Date of Death Age If Veteran of U.S.Armed Forces, 11/26/2017 59 Years War or Dates 1976-1979 Place of Death Hospital, Institution or tZ City, Town or Village Glens Falls Street Address Glens Falls Hospital 9Manner of Death©Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ri❑Pending Circumstances Investigation w Medical Certifier Name Title Suzanne Rayeski DO Address 4 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number ri City, Town or Village Glens Falls 5601 611 ❑Burial Date Cemetery or Crematory 11/29/2017 Pine View Crematorium ❑Entombment Address ®Cremation Queensbury Town, New York Date Place Removed Z❑Removal and/or Held and/or Address Hold Date Point of to❑Transportation Shipment 12 by Common Destination Carrier ,z'❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address W s Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Stpo Box 67,Hudson Falls,New York 12839 ` Name of Funeral Firm Making Disposition or to Whom -I Remains are Shipped, If Other than Above X Address at Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/28/2017 Registrar of Vital Statistics 4t9fen.4 Curtis EkctronicaaySigned- (signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: In Date of Disposition /2-II /7 Place of Disposition pm 2 U'04n . ry (address) 0 (section) (I number) (grave number) '= Name of Sexton o rs in Charge of Premises -`to !r +� (please print) Signature Title f'.Q fryt (over) DOH-1555 (02/2004)