Poolet, Jr. Alexander NEW YORK STATE DEPARTMENT OF HEALTH 4 qcy_-
Vital Records Section 3 Burial - Transit Per it
Name First Middle Last Sex
Alexander C. Poolet Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
09/14/2011 6A years War or Dates 1961-1965
j- Place of Death Hospital, Institution or
City, TovqiX Glens Falls Street Address
V Manner o eath❑Natural Cause Accident 0 Homicide 0 Suicide Undetermined ri❑Pending
Circumstances Investigation
W Medical Certifier Name Title
Mary Nilayko M D
Address
100 Park St Glens Falls, Ny 12801
Death Certificate Filed District Number Register Number
City, Towiheiyilimyy Glenc Falls 5801 408
[Burial Date Cemetery or Crematory
['Entombment Address
Pine View Crematorium
Address
❑Cjemation Oueensbury NY 12804
Date Place Removed
Z
❑Removal _ and/or Held
2 and/or Address
Hold
tfl
0 Date Point of
N0 Transportation Shipment
5 by Common Destination
Carrier _
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Edward L. Kelly Funeral Home 00519
Address
Schroon Lake, N Y 12870
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
g Address 421
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/15/2011 Registrar of Vital Statistics LAD c k-kty`g (Jo
(signature)
District Number Place
5801 Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LLI Date of Disposition 1 IA,ill Place of Disposition cg '`-p.s I � j Cate- L dv luk.` •
2 1 (address)
w
t`/
CC (section) (lot number (grave number)
ta Name of Sexton or Pers n in Charge of Premises �s.Iti-- f J rA,J't4--
z (please print)
La
Signature Title ZQ,e triterdil
(over)
DOH-1555 (02/2004)