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Woutersz, Joseph NEW YORK STATE DEPARTMENT OF HEAL TH rti� Vital Records Section ! ; 1 Burial - Transit Permit Name First Middle Last Sex Joseph Albert Woutersz Male - Date of Death Age If Veteran of U.S. Armed Forces, Aid 5, 2016 67 War or Dates I Placey:' eath Hospital, Institution or WCity, V • r or Village Queensbury Street Address 19 Wintergreen Road 0 Manner of Death J Natural Cause ID Accident Ei Homicide El Suicide LiUndetermined ri Pending UCircumstances Investigation W Medical Certifier Name Title CI Ageel Gillanni, Address 102 Park Street Glens Falls, NY 12801 Death --ificate Filed District Number ,Esser Number City, Town sr Village Filed- er,S 6LAr'y 5657 `�� ❑Burial Date Cemetery or Crematory April 7, 2016 Pine View Crematorium ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed Removal z.� and/or Held and/or Address F. Hold ` Date Point of tTransportation Shipment ICO by Common Destination . Carrier Disinterment Date Cemetery Address _ Reinterment 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 I—z Remains are Shipped, If Other than Above 2 Address IX IL a" Permission is hereby granted to dispose of the human re a' s descri ed ab a as indicated. I I of Registrar of Vital Statistics , vU ,,\ � Date Issued � 9� �-� (ignature) District Number 5657 Place �, �� CD • • Ik J I certify that the remains of the decedent identified above were Osposed of in a cordanc-! this permit on: .7'18'V re-0 /L0t44r^ LI.I' Date of Disposition 04/07/2016 Place of Disposition Quaker Road Queensbury,NY 12804 2 (address) CO I5 (section) (lot mber) (grave number) 0= Name of Sexton or erson i harge of Premises r'i Cvi L Z J. ' Z 2viefe (please print) Signature J G/! Title 6'12ine- (over) DOH-1555 (02/2004)