Hafey, Paul NEW YORK STATE DEPARTMENT OF HEALTh . 1 ( 8
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Paul Nicholas Hafey Male
44
Date of Death Age If Veteran of U.S. Armed Forces,
June 22, 2017 64 War or Dates
ter Place of Death Hospital, Institution or
WCity, Town or Village Fort Edward Street Address 36 Perkins Drive
Manner of Death Natural Cause 0 Accident Homicide Suicide Undetermined Pending
e' Circumstances Investigation
W Medical Certifier Name Title
0 Michael Sikirica MD,
Address
50 Broad Street Waterford, NY 12188
District Number 5r7 5.� Register Number a;�
Death Certificate Filed �V
''` ' City, Town or Village
Burial Date Cemetery or Crematory
June 26, 2017
El,„Entombment Address
Cremation
Date ' Place Removed
Removal and/or Held
o and/or Address
'1.1, Hold
171 Date Point of
Q,❑Transportation Shipment
Cl), by Common Destination
a Carrier
1,4 Disinterment
Date Cemetery Address
1:1Reinterment 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
r Remains are Shipped, If Other than Above
lac. Address
W
-1". Permission is hereby ranted to dispose of the hum n r ins described a ove as'ndicated.
' Date Issued Q( Registrar of Vital Statistics ,
�� (signature)
District Number r5'( Place I 7L. lJ Qd
4 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
�' Date of Disposition 06/26/2017 Place of Disposition RN / �rr N4rA.,.3
p P
(address)
a
M. (section) lot number) (grave number)
Name of Sexton or Person in Charge Premises r+ �'"'t`�!
(p1 se print
P Signature ut Title (t tnu It
(over)
DOH-1555 (02/2004)