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White, Theodore -t �, - ff 710 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section _ Burial - Transit Permit Name First Middle :,,' Last Sex Theodore Wayne White Male Date of Death Age If Veteran of U.S. Armed Forces, October 18, 2016 72 WaE.or Dates Vietnam IPlace of Death Hospital, Institution or C. Town or Village Glens Falls Street Address Glens Falls Hospital WManner of Death jj Natural Cause Accident Homicide Suicide Undetermined Pending Circumstances Investigation W Medical Certifier Name Title L Darci Gaiotti-Grubbs, Dr. Address 102 Park Street Glens Falls, NY 12801 Death Certificate Filed District Number Register Number City, Town or Village U(OO i ❑Burial Date Cemetery or Crematory October 21, 2016 Pine View Crematorium ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z 0 Removal and/or Held O and/or Address Hold 01 Date Point of p. OTransportation Shipment 10) by Common Destination E 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 F--, Remains are Shipped, If Other than Above Z Address w C Permission is h re y granted to dispose of the human r ains escribed bove as i dicated. Date Issued 0 I 0 ' i Registrar of Vital Statistics } (signature) District Number Place c� ,_ / Lam, I certify that the remains of the decedent identified above were disposed of in accordance ith this permit on: W; Date of Disposition 10/21/2016 Place of Disposition Quaker Road Queensbury,NY 12804 2 (address) (section) (lot number) (grave number) 0 Name of Sexton or Person in Charge of Premises Zj,, L. s^Atirk. Z (please print) W Signature al .41 Title No.ith MU- (over) DOH-1555 (02/2004)