Francis, Rodney 4
NEW YORK STATE DEPARTMENT OF HEALTH kact Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Rodney Earl Francis Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 16, 2016 69 War or Dates Vietnam
F— 'lac: of Death Hospital, Institution or
W (City own or Village Glens Falls Street Address Glens Falls Hospital
W anner of Death 0 Natural Cause Accident 0 Homicide Suicide Undetermined ❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
CI Farhana Kamal,
Address
/0aPa / k , 6ler)s Fails / Al- V
Ito Certificate Filed _ District Number Registe umber
own or Village Filed -
}-GZ, Is a.P01 ED
• Burial Date Cemetery or Crematory
November 1 , 2016 Pine View Crematorium
Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z Removal and/or Held
• and/or Address
p Hold
Fii Date Point of
eLEl Transportation Shipment
CO by Common Destination
8 Carrier
ElDisinterment Date Cemetery Address
11 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
I Remains are Shipped, If Other than Above
2,, Address
IX
[l Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1 ► ) i g f 24-..'1 G Registrar of Vital Statistics t,J CA.,k, — c c,\
(signatu e)
District Number 5 6c Place G LQA,‘5 -ra \\ c) . N .7
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 11/17/2016 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
Ui
CO
IX (section) (lot number) (grave number)
O Name of Sexton or Person in Charge of Premises V a^7 tl ?ori, bar _,,-1-1
z (please print)
W Signaturi 61az-�- � Title C.vu."^-,--."bc c
(over)
DOH-1555 (02/2004)