O'Leary, Patrick NEW YORK STATE DEPARTMENT OF HEALTH 7„)-ci
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Patrick Scott O'Leary Male
Date of Death Age _ If Veteran of U.S. Armed Forces,
October 4, 2015 62 War or Dates
I- Place of Death Hospital, Institution or
W City, Town or Village Moreau Street Address 18 Snowberry Lane
a W Manner of Death Natural Cause Accident 0 Homicide Suicide Undetermined Pending
Circumstances Investigation
WW, Medical Certifier Name Title
Eric Pillemer, M.D. Dr.
Address
102 Park Street Glens Falls, NY 12801
Death Certificate Filed Distric "�'� Re i r Number
City, Town or Village
❑Burial Date Cemetery or Crematory
October 6, 2015 Pine View Crematorium
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ri Removal and/or Held
and/or Address
H Hold
(f} Date Point of
li C Transportation Shipment
Q) by Common Destination
1 Carrier
Date Cemetery Address
C DisintermentEl
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
tl' Permission is hereby ranted to dispose of the human remai cribed l.v-as indicated.
Date Issued O t 2lkr—Registrar of Vital Statistics }attiU( /
0111 (signet re)
`L
District Number S1 -- Place � r i , , o /d eel Ocyp ,l i ,/ 28
�. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 10/06/2015 Place of Disposition Quaker Road Queensbury,NY 12804
M (address)
W:
Co -
(section) //// (lot nu er) (grave number)
0; Name of Sexton or Person in C arge of Premises G/�r,� !""`�
z
(please print)
W Signature Title -
(over)
DOH-1555 (02/2004)