Plummer, Larry 'NEW YORK STATE DEPARTME' OF HEALTH y /b 1 t.
/Vital Records Section * Burial - Transit Permit
Name First Middle Last Sex
Larry Alanson Plummer Male
' Date of Death Age If Veteran of U.S.Armed Forces,
.` February 18, 2015 76 War or Dates
0 Place of Death Hospital, Institution or
City, Town or Village Hudson Falls Street Address 93 Maple Street
Manner of Death Natural Cause ❑ Accident ❑Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
at Medical Certifier Name Title
eh Aqeel A. Gillani, M.D. Dr.
Address
010 102 Park St Glens Falls, NY 12801
Vs Death Certificate Filed District Number Register Number
City, Town or Village -37.2 to 0 /
0 Burial Date Cemetery or Crematory
February 20, 2015 Pine View Crematorium
:, ❑Entombment
Address
• x®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z❑ Removal and/or Held
tt and/or Address
Hold
r} Date Point of
A
,;❑Transportation Shipment
by Common Destination
94 Carrier
0 Disinterment Date Cemetery Address
E ❑ 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
Remains are Shipped, If Other than Above
__ Address
L
Permission is hereby granted to dispose of the human rem "ns scribed above as indicated.
Date Issued a as•/S Registrar of Vital Statistics „_ 6L7),-Q-Ck
(signature)
�ie District NumberNumber_5-7A 62 Place t� Q
01 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 02/20/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) flot number) i (grave number)
c
Name of Sexton or Person i Char a of Premises .11`i0 ("" J
/ urdif
�1 (Tease print)
i nature �"� Title elzeM
ftrit
� Signature
(over)
DOH-1555 (02/2004)