West, Warren NEW YORK STATE DEPARTMENT OF HEALTH 4 S Z
Vital Records Section
Burial - Transit Fermit
Name First Middle Last Sex
Warren R. West Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 5, 2012 86 War or Dates World War II
F— Place of Death Hospital, Institution or
Ws City, Town or Village Queensbury Street Address The Stanton HCF
W' Manner of Death .i Natural Cause 0 Accident ❑ Homicide ❑ Suicide 0 Undetermined El❑ Pending
3 Circumstances Investigation
W Medical Certifier Name Title
Roslyn Socolof_MD,
Address
100 Broad St Plaza Glens Falls, NY 12801
Death ificate Filed tttcgumber piste Number
CrG Town o illage
❑Burial Date Cemetery or Crematory
October 9, 2012 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
'-Z<❑ Removal and/or Held
a and/or Address
F Hold
a Date Point of
ct, ❑ Transportation Shipment
VI by Common Destination
Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
El Reinterment
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
2 Address
it;
W''
CL. Permission is hereb granted to dispose of the human r ins scr_te.d a v as indicated.
Date Issued I:o1 c �a00,Registrar of Vital Statistics � -t ' ft l,`.,
(signature)
--,
District NumberS(gc') Place j 0 N, CD* l.>`.
F. I certify that the remains of the decedent identified above were disposed of in accordann^ th this permit on:
w' Date of Disposition 0/9 lit Place of Disposition -R�°to.) (�rv►4oyr;0"--
2 (address)
W;,'.
W (section) . lot number) S
(grave number)
aName of Sexton or Person in Charge Premises Ahrt «i
z (please print)
W Signature Title Ciff:Net TO&
(over)
DOH-1555 (02/2004)