Carey, Edward I -17 I
NEW YORK STATE DEPARTMENT OF HEALTH '
Vital Records Section Burial - Transit Permit
: Name First Middle Last Sex
::::: Edward John Carey Male
•:r
r`s.: Date of Death Age If Veteran of U.S. Armed Forces,
'0.:,: October 22, 2015 63 War or Dates n/a
:� Place of Death Hospital, Institution or
City, Town or Village Glens Falls sStreet Address Glens Falls Hospital
Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
1Medical Certifier Name Title
rrr: Scott Biasetti,MD
Address
crf.• 100 Park Street,Glens Falls,NY 12801
:;1 Death Certificate Filed District Number Register Number
;7:0.; City, Town or Village 10/26/2015 all s/1
❑Burial Date Cemetery or Crematory
October 27, 2015 Pine View Crematory
❑Entombment Address
❑x Cremation Quaker Road, Glens Falls,NY 12804
Date Place Removed
Z' Removal and/or Held
Z
and/or Address
Hold
co --
0 Date Point of
NI I Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
: Permit Issued to Registration Number
:;: Name of Funeral Home Regan Denny Stafford Funeral Home 01443
▪ Address
:':.: 53 Quaker Road, Queensbury,NY 12804
:r• .: Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
:fit'.:, Permission is hereby granted to dispose of the human remains described above as indicated.
:°;:: Date Issued/6/a /.2d/S Registrar of Vital Statistics LAO CJ,„t.ri-LIJ3 •A
::r (signatu et')
:::•: District Number,,..5-6.id/ Place 6'473 ,' 1/.5 /(/y /c ,0/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z i�
LU Date of Disposition J0 i 21//S Place of Disposition Rnl(L ('*Aw
(address)
W
U)
re (section) A (lot number) (grave number)
QName of Sexton or Person in Char a of Premises (4i;, Ss+ it
Z (please print)
4
Signature Title
(over)
DOH-1555(02/2004)