McCullough, Bernard NEW YORK STATE DEPARTMENT OF HEALTH # 137- M �37_
Vital Records Section Burial - Transit Permit
,Name First Middle Last Sex
Bernard Harold McCullough Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 4, 2015 84 War or Dates Korea
IE Place of Death Hospital, Institution or
w City, Town or Village Fort Edward Street Address 325 Broadway
CD Manner of Death❑ Natural Cause ❑ Accident ❑ Homicide a Suicide ❑ Undetermined ❑ Pending
W Circumstances Investigation
W Medical Certifier Name Title
in Max Crossman MD,
Address
Whitehall Family Health Whitehall, NY
Death Certificate Filed District NumberC��� Registe�Npber
City, Town or Village ��
❑Burial Date Cemetery or Crematory
October 6, 2015 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
} and/or Address
Fi Hold
77 Date Point of
11. n Transportation Shipment
by Common Destination
3 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
H- Remains are Shipped, If Other than Above
M Address
CC
W''
0" Permission is hereb granted to dispose of the human re ins described ahoy a indicated.
Date Issued `Olin1D015 Registrar of Vital Statistics t b-etk V,
,.---- (signature t
`5 District Number 1 Place 'bl.t 06 �t �uvaA
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tl Date of Disposition 10/06/2015 Place of Disposition Quaker Road Queensbury,NY 12804
Z (address)
W'
re (section) got number) (grave number)
pName of Sexton or Person in Charge of Pr mises t r )t8 t
(ple2lse print)
W" Signature d/l. Title
(over)
DOH-1555 (02/2004)