Rempher, Donald NEW YORK STATE DEPARTMENT OF HEALTH E 1 S k Vital Records Section Burial - Transit Permit
eco ds Sect o
Name First Middle Last Sex
Donald Chester Rempher Male
Date of Death Age If Veteran of U.S. Armed Forces,
July 27, 2016 75 War or Dates
F— Place of Death Hospital, Institution or
W City, Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death IL.]Natural Cause ❑ Accident ❑ Homicide 0 Suicide ❑ Undetermined ❑ Pending
W Circumstances Investigation
LU Medical Certifier Name Title
CI Michael Fuller, M.D
Address
100 Park Street Glens Falls, NY 12801 �
Death Certificate Filed District Numb'k Registelner
City, Town or Village
❑Burial Date Cemetery or Crematory
July 29, 2016 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
O and/or Address
Hold
N Date Point of
a. ❑Transportation Shipment
co by Common Destination
C) Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Reinterment
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— Remains are Shipped, If Other than Above
2 Address
re
w
0- Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1 ! 2.9 1- 16 Registrar of Vital Statistics LJ tk,-^..•. j--
(signature) v
District Number c 6D I Place 6 Ci2�S c . \\,5 - 1
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 07/29/2016 Place of Disposition Quaker Road Queensbury,NY 12804
M (address)
W
c
O (section) /� (lot numbs f) (grave number)
p Name of Sexton or Person in Charge Premises ' roil I.
441
Z 7I (please pri t)
W Signature 4 Title « el
(over)
DOH-1555 (02/2004)