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McGovern Sr., William -" NEW YORK STATE DEPARTMENT OF I-IEALTH' Vital Records Section Burial - Transit Permit Name First Middle Last Sex William McGovern Sr. Male Date of Death Age / If Veteran of U.S. Armed Forces, September 23, 2017 Wb War or Dates I : Place of Deat► /--- Hospital, Institution or a City, Town or Village age South Glens Falls Street Address 4 1/2 Fairview Street Ld Manner of Dea p4 Natural Cause ❑ Accident ElHomicide ElSuicide ❑ Undetermined ❑ Pending Y Circumstances Investigation W Medical Certifier Name Title al Craig A. Emblidge, Dr. Address 3 Irongate Center Glens Falls, NY 12801 Death Certificate Filet-- District Number Register Number City, Town orqillag) o Lt - ' (oix v$$ {�tA-) ❑Burial Date Cemetery or Crematory September 25, 2017 Pine View Crematorium ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed 2i❑ Removal and/or Held and/or Address E Hold fl Date Point of 0. ❑Transportation Shipment Q) by Common Destination 0 Carrier ❑ Date Cemetery Address Disinterment ❑ Reinterment Date Cemetery Address _ Permit Issued to Registration Number `- Name of Funeral Home Carleton Funeral Home, Inc. 00281 ;„ 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 IX LU L. Permission is h reby granted to dispose of the human remains escribed above as in 'cated. Registrar of Vital Statistics �C�r� �" Date Issued /7 g � L�/l Q>Z . _ i nature) District Number ' 7 & /4/4 ., la_� g4u r�rt Place rx, I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 7,u1 Date of Disposition 09/25/2017 Place of Disposition Quaker Road Queensbury,NY 12804 t. (address) (section) / (lot number) ( (grave number) Name of Sexton or Person in Charge of Pre ises 1 bris e` J[wig " (pie se print) 1.1" Signature L✓l h'tr Title h (over) DOH-1555 (02/2004)