Deyoe, Walter NEW YORK STATE DEPARTMENT OF HEALTH
e N # tfl D
Vital Records Section / Burial - Transit Permit
44 Name First Middle Last Sex
Walter Jay Deyoe Male
Date of Death Age If Veteran of U.S.Armed Forces,
. June 25, 2016 86 War or Dates
I' Place of Death Hospital, Institution or
City, Town or VillageLIJ Argyle Street Address Washington Center
W Manner of Death .J Natural Cause 0 Accident ❑ Homicide ❑ Suicide ❑ Undetermined 0 Pending
Circumstances Investigation
W Medical Certifier c Nam% Title
Address
- ; Death Certificate Filed ri'J 1 District Number ��5o Register Number
City, Town or Village t)
rBurial Date Cemetery or Crematory
:'0 June 28, 2016 Pine View Crematorium
a
, ❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
. ❑ Removal and/or Held
= and/or
a
Hold Address
Vy, Date Point of
a ❑Transportation Shipment
by Common Destination
' Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Reinterment
..i 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
' Address
It
,LI1
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 6 i ' )/b _ Registrar of Vital Statistics Ng,ke Le"
I (signature)
District Number 5'756 Place LI 1 /
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
in Date of Disposition 06/28/2016 Place of Disposition Quaker Road Queensbury,NY 12804
2; (address)
w
co
ce (section) n (lot number) r (grave number)
Name of Sexton or Person in Charge f Premises 6 nf-t .J`.i(
,. ( ease print)
W Signature a Title Catn'ii74
1
(over)
DOH-1555 (02/2004)