Flagg, Wayne NEW YORK STATE DEPARTMENT OF HEALTH 1f VI kl
Vital Records Section �,,; , Burial - Transit Permit
Name First Middle Last Sex
Wayne Arthur Flagg Male
Date of Death Age If Veteran of U.S. Armed Forces,
June 2, 2012 57 War or Dates
Place of Death Hospital, Institution or
w City, Town or Village Glens Falls Street Address The Pines
W Manner of Death X❑ Natural Cause III Accident ❑ Homicide El Suicide El Undetermined ❑ Pending
C, Circumstances Investigation
W" Medical Certifier Name Title
0` Suzanne Rayeski, D.O.
Address
170 Warren Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village 5601k P
❑Burial Date Cemetery or Crematory
June 5, 2012 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Piace Removed
z ❑ Removal and/or Held
a and/or Address
p Hold
_
0 Date Point of
a. ❑ Transportation Shipment
O by Common Destination
fa Carrier
Date Cemetery Address
El Disinterment
Date Cemetery Address
I: Reinterment
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
f- Remains are Shipped, If Other than Above
Address
W
CL Permission is hereby granted to dispose of the human remains descr' a ab ve s in d.
Date Issued Oi v2Registrar of Vital Statistics
(signature)
District Number 5601 Place C . ,/?q/7 Ai/
I certify that the remains of the decedent identified above were disposed ofofn in accordance with this permit on:
LwjJ', Date of Disposition (,ft.ilt Place of Disposition P/�U eiJ Cphryf oriv%-
Z i (address)
W
re (section) (lot number) (grave number)
a. Name of Sexton or Pe on in Charge f Premises �►fi'�"`l'r'" S tiv-lli
z
(please print)
W Signature L. Title c► ►�i��O'Q—
(over)
DOH-1555 (02/2004)