Whittington, Richard NEW YORK STATE DEPARTMENT OF HEALTH
# SP/
Vital Records Section N Burial - Transit Permit
,
. Name First Middle Last Sex
Richard Stanley Whittington Male
Date of Death Age If Veteran of U.S. Armed Forces,
July 20, 2016 64 War or Dates
ggPlace of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address 5 Perkins Drive
Manner of Death i Natural Cause Ej Accident Ej Homicide El Suicide Undetermined 17 Pending
Circumstances Investigation
bt Medical Certifier Name Title
P
Address
0 Death Certificate Filed District Number Reg Number
,i1 City, Town or Village 51 55
0 Burial Date Cemetery or Crematory
July 22, 2016 Pine View Crematorium
3 0 Entombment Address
W ®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
Removal and/or Held
and/or Address
Hold
Date Point of
t 0 Transportation Shipment
by Common Destination
: : Carrier
0 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
Remains are Shipped, If Other than Above
Zi Address
I
Pe:::
is hereby granted to dispose of the hum s d scribed v dicated.
t 1 0 tcp Registrar of Vital Statistics jj
ignature)
District Number 3155 Place 16u 4 , �au)Q..., ,
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7,. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 07/22/2016 place of Disposition Quaker Road Queensbury,NY 12804
(address)
W
(section) (lot number) CC (grave number)
Name of Sexton or Person in Charge of P emises a etsy .l_
(pidase print)
Signature Title CMr 7 t
(over)
DOH-1555 (02/2004)