Kaetzel, Randy NEW YORK STATE DEPARTMENT OF HEALTH f • CZ—
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Randy Wayne Kaetzel Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 16, 2015 58 War or Dates
I Place of Death Hospital, Institution or
W City, Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death Natural Cause Accident 0 Homicide 0 Suicide Ej Undetermined El Pending
Circumstances Investigation
Medical Certifier Name Title
'' Frances Bollinger MD,
Address
161 Carey Rd Queensbury, NY 12804
Death Certificate Filed District Number R tp-s j\lumber
City, Town or Village 5601 0
❑Burial Date Cemetery or Crematory
October 21, 2015 Pine View Crematorium
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
Z n' Removal and/or Held
L_. and/or AddressHold
CO Date Point of
eL n Transportation Shipment
by Common Destination
C ' Carrier
ElDisinterment Date Cemetery Address
ElReinterment 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
I— Remains are Shipped, If Other than Above
Address
W
Permission is he b . granted to dispose of the human rema i •e ribed above as indi
Date Issued 0 /3' Registrar of Vital Statistics %� //
�� v(signature)
District Number 5601 Place � /
I certify that the remains of the decedent identified above were disposed of in accorda a with this permit on:
W; Date of Disposition 10/21/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
Wi
c (section) i (lot numbe - (grave number)
a Name of Sexton or Person in Cha e of Premises L '►r�� � 3/'A
I (please print)
W Signature "" Title 1
-601
(over)
DOH-1555 (02/2004)