O'Leary, Daniel NEW YORK STATE DEPARTMENT OF HEALTH L BUrI1I - Transltb�ermlt
Vital Records Section
Name First Middle Last Sex
Daniel John O'Leary Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 11, 2011 68 War or Dates
ZPlace of Death Hospital, Institution or
w City, Town or Village Glens Falls Street Address 10 First Street
WManner of Death Natural Cause ❑ Accident El Homicide ❑ Suicide El Undetermined ❑ Pending
0 Circumstances Investigation
W Medical Certifier Name Title
Ci Timothy Murphy,
Address
52 Haviland Ave Glens Falls, NY 12801
Death Certificate Filed District NS,r int 1 RegiC nter
City, Town or Village `
❑Burial Date Cemetery or Crematory
November 14, 2011 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
p Hold Pine View Crematorium
N Date Point of
EL ❑Transportation Shipment
CD by Common Destination
Q Carrier
Date Cemetery Address
III 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
Remains are Shipped, If Other than Above
2 Address
W
1" Permission is hereby granted to dispose of the human remains de r be abo as i ed.
Date Issued // /'f/20 1/ Registrar of Vital Statistics
/ (signature)
District Number 6-6,0 Place r7e1- -_/4, ' _/
rI certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
iij Date of Disposition 00J I q 2ckt P
Place of Disposition glin.• C Ofu.---
(address)
LU
W (section) (lot number) < (grave number)
0 Name of Sexton or Person in Charge o- Premises �ctst k J
(phase print)
W SignatureZ
Title (e m qjo&
(over)
DOH-1555 (02/2004)