Latterell, Mark NEW YORK STATE DEPARTMENT OF HEALTH - - lik i 6
Vital Records Section Burial -ilia
Permit
Name First Middle Last Sex
Mark Latterell Male
Date of Death Age If Veteran of U.S. Armed Forces,
March 2, 2016 55 War or Dates
N Place of Death Hospital, Institution or
te, City, Town or Village Glens Falls Street Address Glens Falls Hospital
0 Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
w Circumstances Investigation
a
W Medical Certifier Name Title
C3 Eric Pillemer, M.D. Dr.
Address
102 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register N)am r
City, Town or Village 5601
❑Burial Date Cemetery or Crematory
March 3, 2016 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
ElRemoval and/or Held
• and/or Address
};, Hold
CO Date Point of
aa.. ❑Transportation Shipment
COby Common Destination
O 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
= Address
c
W;
L1,-- Permission is hereby granted to dispose of the human remains described above as ndicated.
Date Issued 3 / 3 1 / 6 Registrar of Vital Statistics L �-'`''''-cf\J‘St-'
(signature)
District Number 5601 Place 6 �.A.-\.S Val,_ V. \ S/ Nk_.?)
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H:
WF Date of Disposition 03/03/2016 Place of Disposition Quaker Road Queensbury,NY 12804
2 (address)
W`
W (section) (lot number) (grave number)
O• Name of Sexton or Person in Charge of Pr mises 4ir� ,s-.0-
(please print)
W Signature i(1 Titleikt
(over)
DOH-1555 (02/2004)