Lovett Sr, Howard NEW YORK STATE DEPARTMENT OF HEALTH* 1 If ('
Vital Records Section Burial - Transit Permit
--, Name First Middle Last Sex
Howard Thomas Lovett, Sr. Male
- ' Date of Death Age If Veteran of U.S. Armed Forces,
January 27, 2015 77 War or Dates
it
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 20 Queensbury Ave'
Manner of Death 0 Natural Cause El Accident 0 Homicide 0 Suicide 0 Undetermined 0 Pending
Circumstances Investigation_
, Medical Certifier Name Title
<t Robert L Evans DO,
Address
1 Irongate Center Glens Falls, NY 12801
Dea h- - ificate Filed Dis t Number Register Number
- ' CittTown r Village cL,i v4}- (9 "S 13.
❑Burial Date Cemetery or Crematory
February 2, 2015 Pine View Crematorium
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
0 Removal and/or Held
and/or Address
__ Hold
�' Date Point of
IltEi Transportation Shipment
by Common Destination
Carrier
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
.4.,„.4 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
E Remains are Shipped, If Other than Above
Address
Qt Permission_is hereby granted to dispose of the human r:m ins d_esc ed a v as indicated.
4
` Date Issued 1 I:U`l ) S Registrar of Vital Statistics l (L,t,
_ (signature)
IF' ' District Number (vc'-) Place ) 0 CN'T (..... .),....e.e... ).)
'1,4a
;-',1, -
I certify that the remains of the decedent identified above were disposed of i accordanc with this permit on:
iliz Date of Disposition 02/02/2015 Place of Disposition Quaker Road Queensbury,NY 12804
2- (address)
iit
CO,
lid' (section) A (lot number) ( (grave number)
Name of Sexton or Person in Charge o Premises r=, 1 Sow*
Z= (
u Signature Title ease print)
(over)
DOH-1555 (02/2004)