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Grubb, George NEW YORK STATE DEPARTMENT OF HEALTH # I00 Vital Records Section Burial - Transit Permit Name First Middle Last Sex George Thomas Grubb Male Date of Death Age If Veteran of U.S. Armed Forces, February 2, 2017 66 War or Dates Place of Death Hospital, Institution or 1JJ, City, Town or Village Glens Falls Street Address Glens Falls Hospital WM• anner of Death ❑Natural Cause ❑ Accident D Homicide ❑ Suicide ❑ Undetermined ❑,Pending jH Circumstances Investigation W- Medical Certifier Name Title CI Robert Beaty MD, Address 100 Broad St. Glens Falls, NY 12801 Death Certificate Filed District Number Register Number City, Town or Village ❑Burial Date Cemetery or Crematory February 3, 2017 Pine View Crematorium 0 Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed • z ❑ Removal and/or Held O and/or Address .. , F., Hold Pine View Crematorium 0 Date Point of • ❑Transportation Shipment (I) by Common Destination C Carrier Date Cemetery Address ❑ Disinterment ❑ Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home, Inc. 00281 A• ddress Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839 Name of Funeral Firm Making Disposition or to Whom F- Remains are Shipped, If Other than Above -2- Address W CL P• ermission is here granted to dispose of the human kmains escribed above as ndic 1ted. Date Issued Registrar of Vital Statistics gu-e_,.J, /�2 OP-C.. (signature) District Number Place ./ere-e4b0 4a..--t: „ �� I certify that the remains of the decedent identified above were disposed of in accor ance with this permit on: I—: WT Date of Disposition 02/03/2017 Place of Disposition Quaker Road Queensbury,NY 12804 2 (address) W, CO- : (section) (lot number) c .iv1 (grave number) Name of Sexton or Person in Charge of Premises l,r' , z ( lease print) W Signature 14lg Title / AVI (over) DOH-1555 (02/2004)