Park, Jeffrey NEW YORK STATE DEPARTMENT OF HEALTH 4 # )0
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Jeffrey Glenn Park Male
Date of Death Age If Veteran of U.S. Armed Forces,
September 23, 2016 69 War or Dates
t~ %'-c= of Death Hospital, Institution or
City own or Village Glens Falls Street Address Glens Falls Hospital
d .nner of Death Natural Cause ❑ Accident El Homicide ❑ Suicide ❑ Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
i i Eric Pillemer, M.D. Dr.
Address
102 Park Street Glens Falls, NY 12801
=a Certificate Filed District Number / Register N r
ity own or Village ( j (e, S •Fa,1(3 5a . / - 73
• :urial Date Cemetery or Crematory
September 29, 2016 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z Removal and/or Held
and/or Address
Hold
Date Point of
I I Transportation Shipment
N by Common Destination
O Carrier
111 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- Remains are Shipped, If Other than Above
2 Address
W
Permission is he eby ranted to dispose of the human remains de cribed ab 'ye as indica ed.
Date Issued Registrar of Vital Statistics O(Leyl
(signature)
14
District Number (a)/ Placej
I certify that the remains of the decedent identified above were disposed of in accordant with this permit on:
W Date of Disposition 09/29/2016 Place of Disposition Quaker Road Queensbury,NY 12804
2 (address)
W
(section) (lot number) ((�� (grave number)
ci Name of Sexton or Person in Charge f Premises
z! / ( ase print)
W Signature LL Title hi -
(over)
DOH-1555 (02/2004)