Davis, Criag NEW YORK STATE DEPARTMENT OF HEALTH 4 41
Vital Records Section i IF
Burial - Transit P rmit
Name First Middle Last Sex
Craig William Davis Male
Date of Death Age If Veteran of U.S. Armed Forces,
September 20, 2011 61 War or Dates
Place of Death Hospital, Institution or
w City, Town or Village Glens Falls Street Address Glens Falls Hospital
CI Manner of Death Li Natural Cause ❑ Accident ❑ Homicide 0 Suicide El Undetermined ❑ Pending
{.?; Circumstances Investigation
LU Medical Certifier Name Title
Erick Pillemer, M.D. Dr.
Address
102 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village 5601
❑Burial Date Cemetery or Crematory
September 26, 2011 Pine View Crematorium
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
{ and/or Address
E Hold Pine View Crematorium
GO Date Point of
p ❑Transportation Shipment
0) by Common Destination
ri Carrier
Date Cemetery Address
El Disinterment
Date Cemetery Address
El 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
Ce
O. Permission is hereby granted to dispose of the human remains described aboxe as indicated.
Date Issued q l Z 3)of Registrar of Vital Statistics W Cam ,U
� rr__ (signature)
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District Number 5601 Place 6 "J +-ek k\ S ,N 4
• I certify that the remains of the decedent identified above were disposed-of in accordance with this permit on:
ID Date of Disposition 1(j61i( Place of Disposition Po40to) Cw+.a�ohU.-
X, (address)
W.
C (section) _ (lot numbs( (grave number)
0 Name of Sexton or P rson in Char a of Premises iir'sA r h,,,A-
Z (please print)
i
W Signature � Title (.¢DWI‘ Jt_
(over)
DOH-1555 (02/2004)