Bills III, Carl # T)O
NEW YORK STATE DEPARTMENT OF HEALT lk,
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
„.,40 Carl J. Bills,III Male
Date of Death Age If Veteran of U.S. Armed Forces,
April 8,2015 21 War or Dates
Place of Death Hospital, Institution or
Z; City, Town or Village Glens Falls Street Address Glens Falls Hospital
e ° Manner of Death X Natural Cause Accident Homicide n Suicide Undetermined Pending
W. Circumstances Investigation
Medical Certifier Name Title
Suzanne Rayeski
4- Address
9
3767 Main Street,Warrensburg,NY 12885
c Death Certificate Filed District Number Register Number 1��
:i:: City, Town or Village Glens Falls
❑Burial Date Cemetery or Crematory
April 10,2015 Pine View Crematory
❑Entombment Address
❑x Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
co
0 Date Point of
a.
cn Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
ri Reinterment Date Cemetery Address
Permit Issued to Registration Number
z Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
° " 3809 Main Street,Warrensburg, NY 12885
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Via,
ILL
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued y 1 10 I. 15 Registrar of Vital Statistics
CJ` v —_ (signature)
District Number 5 6 O! Place Glens Falls 7 W
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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Z
w Date of Disposition (4-(3-(c Place of Disposition 4,,,. 6 - ;,,�
2 (address)
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0
Ce
0. (section) //� (tot numbert- (grave number)
p Name of Sexton or Person in Charge of Premises 6' J
Z please print)
IliSignature Title 67r�r }
(over)
DOH-1555 (02/2004)