Weils, Timothy NEW YORK STATE DEPARTMENT OF HEALTH ;
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Timothy James Weils ' Male
Date of Death Age If Veteran of U.S. Armed Forces,
August 12, 2015 49 War or Dates
I Place of Death II`` Hospital, Institution or
Ili City, Town or Village K;A S bid r Street Address State Route 4
W Manner of Death❑ Natural Cause ILE Accident 0 Homicide ❑ Suicide Undetermined El Pending
Circumstances Investigation
W Medical Certifier Name Title
CI Max Crossman, M.D. Dr.
Address
Whitehall Family Health Whitehall, NY 12887
Death Certificate Filed District Number Registriumber
City, Town or Village 5-76 /�
0 Burial Date Cemetery or Crematory
August 14, 2015 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
zriRemoval and/or Held
and/or Address
F. Hold
Date Point of
❑Transportation Shipment
U) by Common Destination
Ei Carrier
Disinterment Date Cemetery Address
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
CC
Ill''.
Cs-
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01 - pi- /S Registrar of Vital Statistics a6 �x
(signature)
District Number ,. 7 (21, Place --7-/,,v A Q -1 I'.-.15 S 6 u i.
. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 08/14/2015 Place of Disposition Quaker Road Queensbury,NY 12804
2' (address)
wco
re (section) A (lot number) (grave number)
in Name of Sexton or Person in Charge of Premises 1 L 5 e
z ( lease print)
Ill Signature LTitle "M► t
(over)
DOH-1555 (02/2004)