Meade, Theodore NEW YORK STATE DEPARTMENT OF HEALTH # 2(.
Vital Records Section Burial - Transit Permit
„' Name First Middle Last Sex
Theodore Franklin Meade Male
Date of Death Age If Veteran of U.S. Armed Forces,
April 5, 2015 86 War or Dates World War II
Place of Death Hospital, Institution or
Ill City, Town or Village Fort Edward Street Address FORT HUDSON HEALTH CARE FAC.
0 Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
I Circumstances Investigation
eta Medical Certifier Name Title
ir Philip Gara, M.D. Dr.
Address
Broadway Fort Edward, NY 12828
Death cate Filed � } } District NumberRegist umber
City, own r Village o� ��w mG-iJ _ 59 5
W 1-7
Date Cemetery or Crematory
Buria April 7, 2015 Pine View Crematorium
`",❑Entombment Address
NCremation Quaker Road Queensbury,NY 12804
„; Date Place Removed
;,� Removal and/or Held
0 and/or Address
g Hold
V Date Point of
Transportation Shipment
41 by Common Destination
0 Carrier
Disinterment Date Cemetery Address
/ Reinterment Date Cemetery Address
f 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
41 Name of Funeral Firm Making Disposition or to Whom
I- Remains are Shipped, If Other than Above
Address
I ,
4' Permission is he eb granted to dispose of the human r ' s describ d apowe s i .dicated
iFP Date Issued !-4 li j Registrar of Vital Statistics ,
(signature)
District Number 5955 Place 1 61,07k 06 frOlk td,t,uctAci
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
i-%
6. Date of Disposition 04/07/2015 Place of Disposition Quaker Road Queensbury,NY 12804
i (address)
of number) (grave number)
0
(section) �1
n Name of Sexton or Person in Charge of Premises 14 rrti ✓2 A .
(please print)
W Signature I-- Title ritoY`bT1.01-
(over)
DOH-1555 (02/2004)