Hall 111, George Edward Asa
111, # ) I(1Z
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
George Edward Hall Ill Male
Date of Death Age If Veteran of U.S.Armed Forces,
10/17/2020 81 Years War or Dates
Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death Natural Cause 0 Accident 0 Homicide Suicide El Undetermined ❑Pending
Circumstances Investigation
W Medical Certifier Name Title
Abigail Macomber PA
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 476
❑Burial Date Cemetery,Crematory or Facility Name
10/19/2020 Pine View Crematorium
Entombment Address
X❑Cremation Queensbury Town,New York
▪Donation
ZZ ❑Removal Date Place Removed
and/or and/or Held
i- Hold Address
0
d Date Point of
t/) L j Transportation Shipment
p by Common
Carrier Destination
❑Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address
68 Main Street,P.O.Box 67,Hudson Falls,New York 12839
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
2 Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/19/2020 Registrar of Vital Statistics 'R96ertAndfrew Curtis(ECectronicalty Signed)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition /V ZOO 10 Place of Disposition
Z37-
1.1J (address)
W
CC CC (section) Imbed (grave number)
S Name of Sexton or Person in Charge o{Premisestik 1111
(please pint)
g
• Si nature /it� —/��� Title rtrrpt
DOH-1555(07/18)p t of 2
Public Health Law Sec. 4145(2b) 014132
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#