Hamell, Alan i
NEW YORK STATE DEPARTMENT OF HEALTH•
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Alan Troy Hamell Male
Date of Death Age If Veteran of U.S. Armed Forces,
' December 16, 2017 53 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 142 Adirondack Way
Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide 0 Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
LU Medical Certifier Name Title
Paul F Bachman MD,
��
Address
Warrensburg Health Center Warrensburg, NY 12885
Death Certificate Filed District Number �J1�5 Register Number
, City, Town or Village 7 1 VU
❑Burial Date Cemetery or Crematory
December 22, 2017 Pine View Crematorium
0 Entombment Address
I Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
Removal and/or Held
, Li
and/or
Address
Hold
Date Point of
-ILP. ❑Transportation Shipment
by Common Destination
CI Carrier
_ _ ❑ Disinterment Date Cemetery Address
a El Reinterment Date Cemetery Address
41 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
`1r Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
. Address
W
T'L Permission is hereby granted to dispose of the human remains described above as indicated.
t Registrar of Vital Statistics !�
Date Issued l�- g- ao Il g `n /44A 'A.1%-kt,it_.e-/DA--,
(signature)
District Number rjk,rj 'j Place QL c n S kL1/
I certify that the remains of the decedent identified above were isposed of in accordance with this permit on:
W;; Date of Disposition 12/22./2017 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) \ (lot number) (grave number)
C!:
Name of Sexton or fr on " Charge of Premises Jv it I4'L 6�,"�``�c'�
(please print)
W i,, Signature A/ �. Title C.-r.�rn ,:h`.�
(over)
DOH-1555 (02/2004)