Trackey, Arthur L1 G
NEW YORK STATE DEPARTMENT OF HEALTH Li
Vital Records Section ' Burial - Transit Permit
Name First Middle Last Sex
44-4,4 Arthur Jerome Trackey Male
;- Date of Death Age If Veteran of U.S. Armed Forces,
December 25, 2015 88 War or Dates World War II
Place of Death Hospital, Institution or
6-4 City, Town or Village Fort Edward Street Address FORT HUDSON HEALTH CARE FAC.
W° Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
W Medical Certifier Name Title a MD
r GwPridplin MnrriGnn Diekinsnn
Address
,; Glens Falls, NY %2-101
Death Certificate Filed District Number Regi umber
', City, Town or Village Cj 55
❑Burial Date Cemetery or Crematory
December 2f 2015 Pine View Crematorium
4❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
p Hold
E. Date Point of
❑Transportation Shipment
by Common Destination
:3 Carrier
❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
j g 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
44 Name of Funeral Firm Making Disposition or to Whom
F Remains are Shipped, If Other than Above
2` Address
W...............
Permission is hereby granted to dispose of the human r ns described above indicated.
447 a •
Date Issued / g-l5 Registrar of Vital Statistics..
,tL
r— (signature)
r District Number c6r))._J Place ' elLU7'� f- Edwca i
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
/2.29- it Pihe.. U,Yzui G, 0.'
Lui 6 045
Date of Disposition q2'2��� Place of Disposition Quaker Road Queensbury,NY 712804
(address)
Ut
Et (section) (lot number) (grave number)
0 Name of Sexton or Perso in Charge of Premises ) :., l,a.n �e- r e
Z (please print)
Signature . 02 — Title G r 1 r
Am
(over)
DOH-1555 (02/2004)