Greene, George NEW YORK STATE DEPARTMENT OF HEALTH 4 /t 373
Vital Records Section - Burial - Transit Permit
Name First Middle Last Sex
George William _ 3reene Male
Date of Death Age I If'
`-
May 6, 2017 81 _, ar Dates
Place of Death giospital, Institution or
City, Town or Village Hudson Falls J Street Address 53 Main Street, Apt F
Manner of Death X Natural Cause Accidr Homicide Suicide Undetermined Pending
�, Circumstances Investigation
U Medical Certifier Name Title
Anthony Petracca MD,
Address
Three lrongate Ce er Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, O Town or Village 7 7
n 0 Burial Date Cemetery or Crematory
May 8, 2017 Pine View Crematorium
`.0 Entombment Address
` E Cremation Quaker Road Queensbury,NY 12804
1 Date Place Removed
Removal and/or Held
and/or Address
Hold
Date Point of
0 Transportation Shipment
;-0' by Common Destination
# _ Carrier _
IDDisinterment Date Cemetery Address
' ElReinterment 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
Remains are Shipped, If Other than Above
z ,
Address
Permission is hereby granted to dispose of the human r ai described above as indicated.
Registrar of Vital Statistics pc, oar --
� Date Issued 5-3',�U'/� g �-
(signature)
District Number? :AG Place V srw�
I certify that the remains of the decedent identi d bove were disposed of in accordance with this permit on:
Date of Disposition 05/08/2017 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
lot number); ( (grave number)f
Name of Sexton or Person in Charge of P mmises (AC r S.
a Ant'm
(pl ase print)
ii
Signature I-1 47 Title (RUM Oft
(over)
DOH-1555 (02/2004)