Fenton, Daniel NEW YORK 5 IA I t UtHAK I MEN I ur rItHL I n
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Daniel Robert Fenton Male
Date of Death Age If Veteran of U.S. Armed Forces,
August 4, 2011 59 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Saratoga Springs Street Address 3 Smith Bridge Rd,
Manner of Death❑Natural Cause Accident.0 Homicide El Suicide n Undetermined 0 Pending
Circumstances Investigation
Medical Certifier Name Title
Michael Sikirica MD,
Address
50 Broad Street Waterford, NY 12188
Death Certificate Filed District Number Register Number
City, Town or Village
El Burial Date Cemetery or Crematory
August 8, 2011
['Entombment
Address
®Cremation
Date Place Removed
El Removal and/or Held
and/or Address
Hold
Date Point of
ElTransportation Shipment
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
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described ove as indicated.
Date Issued p w Registrar of Vital Statistics `� j k/A/i
(sign ure)
District Number Place 117).
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition $ /' /tL Place of Disposition 2cvJ /, (� cat.vt
yin.
?,o (address)
spa„=a
(section) m (lot MI veer) (grave number)
Name of Sexton or Person in Charg of Premises r Q�
(please print)
Signature Title C riP�--
(over)
DOH-1555(02/2004)