Grinnell, Sr. Earl NEW YORK STATE DEPARTMENT OF HEALTH I
Vital Records Section Burial - Transit ermit
Name First Middle - Last Sex
Earl Eugene Grinnell Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 7, 2012 83 War or Dates
Place of Death Hospital, Institution or
Ci
w ty, Town or Village Glens Falls Street Address Glens Falls Hospital
WManner of Death mI Natural Cause ❑ Accident ❑Homicide ElSuicide ❑ Undetermined ❑ Pending
U Circumstances Investigation
Ui Medical Certifier Name Title
Ci Marvin Davidowitz, M.D
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District NumberC/ Register Number
. City, Town or Village D U/ ) _.,
❑Burial Date Cemetery or Crematory
January 9, 2012 Pine View Crematorium
❑Entombment Address
,_ _. ®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
co and/or Address
p Hold
G) Date Point of
a ❑p. Transportation Shipment
by Common Destination
C; Carrier
❑ Disinterment Date Cemetery Address
❑ Reinterment 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
1-, Remains are Shipped, If Other than Above
2' Address
CE
0. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued ) ) q ( ( 7 Registrar of Vital Statistics W Gt .g
(signature)
District Number 5 6 o Place e XN` A \,\5 IN Y
• I certify that the remains of the decedent identified above were dispos of in accordance with this permit on:
W Date of Disposition 1-t0-0t Place of Disposition i�U,. i C. `ft)(kuti`
2 (address)
W'
re (section) - (lot number)-. (grave number)
dill Name of Sexton or Person i Charge of P mises ►1� ��`��-- SQ""'Imo�\-
Z Signature Title
I (please print)
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(over)
DOH-1555 (02/2004)