Anderson, Carter NEW YORK STATE DEPARTMENT OF HEALTH Burial Records Section Burial - Transit Permit
Name First Middle Last I Sex
T. Carter James Anderson I Male
Date of Death Age If Veteran of U.S. Armed Forces,
June 12, 2015 'ati{r,.fi War or Dates
Place of Death Hospital, Institution or
W= City, Town or Village Glens Falls Street Address Glens Falls Hospital
W£ Manner of Death X❑ Natural Cause El Accident ❑Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
11.1 Medical Certifier Name Title
Ci Jennifer Bashant MD,
Address
102 Park St. Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village
0 Burial Date Cemetery or Crematory
June 18, 2015 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
. Hold
.—
CO Date Point of
a. ❑Transportation Shipment
CO by Common Destination
a Carrier
Date Cemetery Address
❑ 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
I- Remains are Shipped, If Other than Above
2 Address
ce
w
tl' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 6/ /F /( 5 Registrar of Vital Statistics (3C_ . 9U
(signatu )
District Number 5 6 0/ Place 6 Gas g 115 / di
j . I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W, Date of Disposition 06/18/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section __ (lot number) (grave number)
aName of Sexton or Person in Cha e of Premises I i on n-�h../ llrue.r/1e.
Z; `� (please print)
W` Signature Title Cr-c o.,c_k�.y
(over)
DOH-1555 (02/2004)