Weller, Darwin NEW YORK STATE DEPARTMENT OF HEALTH 4 iff
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Darwin Ralph Weller Male
Date of Death Age If Veteran of U.S. Armed Forces,
March 3, 2012 51 War or Dates
I Place of Death Hospital, Institution or
W City, Town or Village Wilton Street Address Lot 318, 100 Gordon lane
WManner of Death Natural Cause ❑ Accident IDHomicide ❑ Suicide ❑ Undetermined ❑ Pending
it.) Circumstances Investigation
W' ' Medical Certifier Name Title
L1
Michael Sikirica MD,
Address
50 Broad Street Waterford, NY 12188
Death Certificate Filed District Number Register N mber
City, Town or Village �5-- g-71
❑Burial Date Cemetery or Crematory
March 5, 2012 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
p Hold
IA Date Point of
❑Transportation Shipment
to by Common Destination
Cl' Carrier
Date Cemetery Address
El Disinterment
Date Cemetery Address
❑ 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
.' Address
Ct
Q' Permission is hereby granted to dispose of the human remai s describedd bye as indicated.
Date Issued c `-5// Registrar of Vital Statistics ��a/�° ��`'�s
( ' ature)
District Number 1/3 Place ` /J/J/2
F-F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
•
u Date of Disposition f r(L li t0i2Place of Disposition i"/j 1) CV1%-olar,u�.
2 (address)
W
CO
CZ (section) 4,1:410141.-
(lot number). (grave number)
a` Name of Sexton or Pers in Charge o Premises ''eh^l
Z I (please print)
W' ,'� Ci? 01A-Tt)�
Si nature � Title �
g
(over)
DOH-1555 (02/2004)