Barnes, George #76
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section - . , Burial - Transit Permit
Name First Middle Last Sex
George Robert Barnes Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 30, 2016 82 War or Dates Korea
Place of Deat Hospital, Institution or
W City, Town o illag0 1/0.1950 fi l f Street Address 189 Dean Road
it3 Manner of Death .i Natural Cause ❑ Accident ❑ Homicide ❑ Suicide n Undetermined ❑ Pending
Investigation
W Medical Certifier Name Title
d Eric Pillemer, M.D. Dr.
Address
102 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village 5-7 e2 I 1
❑Burial Date Cemetery or Crematory
Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
• and/or Address
F Hold GERALD B.H. SOLOMON NAT.
CO
Date Point of GEM.
p,,• 0 Transportation Shipment
01 by Common Destination
5 Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ 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
I— Remains are Shipped, If Other than Above
2 Address
W
'' Permission is hereby granted to dispose of the human remain described above as indicated.
Date Issued cl - I- aoit, Registrar of Vital Statistics C. )Q - )-e
_ (signature)
District Number 5'2 Place ,--,_ 5 L
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition Z/Z./R, Place of Disposition Quaker Road Queensbury,NY 12804 { m Ut.,
2 (address)
W
CO
IX (section) (lot number)c (grave number)
aName of Sexton or Person in Charge o Premises Anita r Son Olt
z (please print)
W Signature Title filEmillit
(over)
DOH-1555 (02/2004)