Levine, Martin NEW YORK STATE DEPARTMENT OF HEALTH `/
Vital Records Section Burial - Transit Permit
Name First Milddle' Last Sex
Martin Alan Levine Male
Date of Death Age If Veteran of U.S. Armed Forces,
June 28, 2011 55 War or Dates
F- Place of Death Hospital, Institution or
ul City, Town or Village Hudson Falls Street Address 70 Oak Street
0 Manner of Death Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
LEI Medical Certifier Name Title
Max Crossman MD,
Address
North St. Granville, NY 12832
Death Certificate Filed District Number Register Number
City, Town or Village kit, 2x.. 1-�y .5-?le 61---
❑Burial Date Cemetery or Crematory
July 2, 2011 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
zriRemoval and/or Held
and/or Address
E Hold
CO Date Point of
� 0 Transportation Shipment
by Common Destination
O Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00276
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
I-- Remains are Shipped, If Other than Above
2 Address
X
tL
tl Permission is hereby
granted to dispose of the human remains described above as indicated.
Date Issued 7/-..,GP Registrar of Vital Statistics o.A ' . /714.1L2i'
(signature)
District Number $-rf',Q f� Place WI/Jr, it ,Adel_h.€413 /I
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition 1'S It Place of Disposition el Uac-i 1.+ ct)l jr,,.,
2 W (address)
(')
it (section) _ (lot number) (grave number)
0 Name of Sexton or P rson in Char e of Premises f 1 Jd h144
Z' (please print)
W' Signature I r Title Cif'-d ,4'(-6Q
(over)
DOH-1555 (02/2004)