Connery, William NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Trantit Permit
Name First Middle Ilk Last Sex
William H. "- k Connery Male
Date of Death Age If Veteran of U.S. Armed Forces,
September 17, 2011 81 War or Dates Korea
ZPlace of Death Hospital, Institution or
w City, Town or Village Fort Edward Street Address FORT HUDSON HEALTH CARE FAC.
WManner of Death Natural Cause IIIAccident Homicide El Suicide ElUndetermined ri Pending
0 Circumstances Investigation
W Medical Certifier Name Title
CI Philip Gara, M.D. Dr.
Address
Broadway Fort Edward, NY 12828
Death Certificate Filed District Number Register Number
City, Town or Village 5_7. --5
❑Burial Date Cemetery or Crematory
September 19, 2011 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date 1 Place Removed
z ❑ Removal and/or Held
and/or Address
E Hold Pine View Crematorium
O Date Point of
❑Transportation Shipment
Cl) by Common Destination
CI 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
1— Remains are Shipped, If Other than Above
2 Address
eL
0.; Permission is h eby ranted to dispose of the human r ins describe ove s indicated.
Registrar of Vital Statistic
Date Issue
,` (signature)
� ,_—„/P1---
District Number2S7 Place/ i-tJ
• I certify that the remains of the decedent identified a ove were disposed of in accordance with this permit on:
WDate of Disposition 11/014 Place of Disposition illmo.c..) Cry_ctoItw...
2 (address)
W'
ft (section)
(lot umber' (grave number)
it-
in Name of Sexton or Per ; in Charge Premises
i'�� r "'�
(pl se print)
W Signature d% Title CtiMATAL
(over)
DOH-1555 (02/2004)