Carter, John I
NEW YORK STATE DEPARTMENT OF HEALTH f Burial - Transit'Permit
Vital Records Section
y
Name First Middle Last Sex
John 0'. Carter Male
Date of Death Age _ If Veteran of U.S.Armed Forces,
F March 11,2011 83 War or Dates 1945-1946
2 Place of Death Hospital, Institution or
ui W _City,Town,or Village Glens Falls New York Street Address Glens Falls Hospital
0 Manner of Death a Natural Cause El Accident El Homicide El Suicide 0 Undetermined 0 Pending
W Circumstances Investigation
U Medical Certifier Name Title
W Evangelas N. Pallis MD
d Address
102 Park Street Glens Falls New York 12887
Death Certificate Filed / District Number Register Number
/,'City, n or Village , ,G L `J 6,0/ /a-3
Burial Date March 15,2011 Cemetery or Crematory.
Pine View Crematorium
❑Entombment Address
®Cremation 21 Quaker Road Queensbury New York 12804
Date Place Removed
0 0 Removal and/or Held
• and/or Address
�' Hold
0 Date Point of
0 0 Transportation Shipment
i by Common Destination
Carrier
Date Cemetery Address
o []Disinterment
0 Reinterment Date Cemetery Address
i
Permit Issued to Registration Number
Name of Funeral Home Jilison Funeral Rome, Inc. 00897
Address
46 Williams Street, Whitehall, New York 12887
F= Name of Funeral Firm Making Disposition or to Whom
2 Remains are Shipped, If Other than Above
CC
W Address
a.
Permission is hereby ranted to dispose of the human remains describ ziyoe a�jndi t
Date Issued 3 __ Z.U// Registrar of Vital Statistics ( /
(signature)
- /
District Number 560/ Place , GP/ </� /1)X
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 3-1C-1a Place of Disposition Pine Vitt.?i amcfor, .
2 (address)
W
!d
0 (section) (lot number) (grave number)
0• Name of Sexton or Person in Charge o Premises af: It Je.wit
Z ( ease print)
W atria_
SignatureTitle CftRkphr4(i/'�--
(over)
DOH-1555 (02/2004)
i