Malmberg, Logan NEW YORK STATE DEPARTMENT OF HEALTH 1 O D
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Logan Conner Malmberg Male
i§ Date of Death Age If Veteran of U.S. Armed Forces,
October 25, 2017 TA t\-Ct War or Dates
Place of Death Hospital, Institution or
ui City, Town or Village Street Address 48 McCrea Street
WManner of Death X❑Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined 1-1 Pending
W Circumstances Investigation
I° Medical Certifier Name Title
Joanne Porter, M.D
Address
43 New Scotland Ave Albany , NY
• Death Certificate Filed District Number r , 4 Regisiumber
City, Town or Village / o
❑Burial Date Cemetery or Crematory
October 26, 2017 Pine View Crematorium
'r❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z;❑ Removal and/or Held
0, and/or Address
E Hold
C Date Point of
eL ❑Transportation Shipment
in by Common Destination
5, Carrier
Date Cemetery Address
❑ Disinterment
ElReinterment Date Cemetery Address
v Permit Issued to Registration Number
r 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
, Remains are Shipped, If Other than Above
Address
ir
tir
• Permission is h eb granted to dispose of the hu =n r_ s de crib d above dicated.
Date Issued N 17- Registrar of Vital Statistics 4 ' t V.
,n-- 1-,, ,/ (signature) C
• District Number 65 Place 16 A A. (�- -L L Q/(Jo
I )
H�
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ay Date of Disposition 10/26/2017 Place of Disposition Quaker Road Queensbury,NY 12804
2` (address)
l;; .
f '
✓ (section) pot number) (grave number)
p Name of Sexton or Person in Charge of Premises (41r,, -- 3 i..+L(
(p/base print)
W Signature F✓`[ Jl� _ Title (4Mr1�D,2
(over)
o-
DOH-1555 (02/2004)