Carlton Sr, Carl NEW YORK STATE DEPARTMENT OF HEALTH . .---%
# 613
Vital Records Section ;, Burial - Transit Permit
Name First Middle Last Sex
Carl William Carlton Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
__ August 23, 2015 82 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Moreau Street Address 1717 Route 9
.. Manner of Death X❑ Natural Cause n Accident 0 Homicide ❑ Suicide n Undetermined n Pending
Circumstances Investigation
` Medical Certifier Name Title
Robert Sponzo, Dr.
Address
1; 102 Park St. Glens Falls, NY 12801
Death Certificate Filed District Number Register,NyyA�mber
City, Town or Village Moreau q515,'Z U
x ❑Burial Date Cemetery or Crematory
August 25, 2015 Pine View Crematory
>,0 Entombment Address
-: `„®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
' ❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
•
Carrier
❑ Disinterment Date Cemetery Address
y„ ❑ Renterment Date Cemetery Address
' ° Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078
Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
r Remains are Shipped, If Other than Above
Address
,.? Permission is hereb granted to dispose of the human remai scribe. •ov as indicated.
Date IssueL)2?/? O/S Registrar of Vital Statistics IVY ( 0
z,= (sig ature)
.
District Number Place 351 ads S ,I �'� ga,/ • /�ZY
53/44;1 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
i Date of Disposition 08/25/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number) (grave number)
. Name of Sexton or Person in Charge of Premises ��.:{ L- St.../4
(pl ase print)
=£' Signature � k Title �¢ tf)rt
(over)
DOH-1555 (02/2004)