Barrows, Sr. Dale NEW YORK STATE DEPARTMENT OF HEALTH` i S I
Vital Records Section Burial - Transit @rmi t
Name First Middle Last Sex
Dale Preston Barrows Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 24, 2011 76 War or Dates
F' Place of Death Hospital, Institution or
W City, Town or Village Glens Falls Street Address Glens Falls Hospital
WManner of Death❑ Natural Cause ❑ Accident ❑ Homicide ❑ Suicide Undetermined El❑ Pending
0Circumstances Investigation
WW,. Medical Certifier Name Title
Joseph Foote MD,
Address
Rt 4 Hudson Falls, NY 12839
Death Certificate Filed Distric. nfnbef((�\ RegZirer•City, Town or Village
❑Burial Date Cemetery or Crematory
October 27, 2011 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z
❑ Removal and/or Held
and/or Address
E Hold
CO Date Point of
11, 0 Transportation Shipment
CO
_ by Common Destination
CI Carrier
Date Cemetery Address
❑ 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
1— Remains are Shipped, If Other than Above
2 Address
W
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date issued j 0/ a6 f f t Registrar of Vital Statistics '
(signature
District Numbe�16 (?c1 , Place G �SJ, --S , ll S 0J y
F I certify that the remains of the decedent.identified above were disposed
of in accordance with this permit on:
W:, Date of Disposition ioiL71'ij Place of Disposition rcUstO Cre<mc{ofi++M-
(address)
Ui
CO
(section) ,i (lot number) (grave number)
c?ca Name of Sexton or Perso in Charge Premises ^t'st "K�
( lease print)
W ��- Ct1&m4TQ�
L1J, Signature Title
g 7
(over)
DOH-1555 (02/2004)