Fullington, Guy NEW YORK STATE DEPARTMENT OF HEALTH It C 10
Vital Records Section Burial - Transit Permit
• `° Name First Middle Last Sex
e Guy Harold Fullington Male
Date of Death Age if Veteran of U.S. Armed Forces,
November 16, 2012 62 War or Dates
F= Place of Death Hospital, Institution or
it City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X Natural Cause Accident V Homicide Suicide Undetermined Pending
fa,1. ❑ ❑ ❑ ❑ ❑ ❑
Circumstances Investigation
,Ur Medical Certifier Name Title
Ageel Gillani, M.D. Dr.
Address
100 Park Street, Pryne Pavillian Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
f- .i City, Town or Village 5601 .,---p2 7
❑Burial Date Cemetery or Crematory
November 21, 2012 Pine View Crematorium
;; 0 Entombment Address
,.®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
" ri Removal and/or Held
and/or Address
Hold
41-1 Date Point of
❑ Transportation Shipment
00") by Common Destination
t Carrier
4i4 Date Cemetery Address
❑ Disinterment
g
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
[ Remains are Shipped, If Other than Above
• Address
t
lif
Permission is hereby granted to dispose of the human remains d d aleve ' ated.
Date Issued /f/zc/20,Z-Registrar of Vital Statistics fi
_//// (signature)
3; District Number 5601 Place 67 po /A77/ � N/ (a col
Off'
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Ali Date of Disposition ii/23jr i Place of Disposition ?inca..› C-iel*Chtr,tdr•
(address)
LU,;
l:
It (section) (lot number) (grave number)
', Name of Sexton or Person in Charge f Premises r', 1
( lease print)
W= Signature Title Calf mil-( ,
(over)
DOH-1555(02/2004)