Ploof, Oliver NEW YORK STATE DEPARTMENT OF HEALTH W54io
Vital Records Section t44 Burial - Transit Permit
Name First Middle Last Sex
Oliver Nathan Ploof Male
Date of Death Age If Veteran of U.S. Armed Forces,
September 4, 2014 80 War or Dates
Place of Death Hospital, Institution or
al City, Town or Village South Glens Falls Street Address 7 Jerome Lane
WManner of Death Lul7r1 Natural Cause Accident ❑Homicide ❑ Suicide Undetermined Pending
C.) Circumstances Investigation
W Medical Certifier Name Title
L4 Richard Farrell, Dr.
Address
15 Maple Dell Saratoga Springs, NY 12866
Death Certificate Filed District Number,��Z Register
City, Town or Village t�
❑Burial Date Cemetery or Crematory
September 5, 2014 Pine View Crematorium
❑Entombment Address
EICremation Quaker Road Queensbury,NY 12804
Date Place Removed
z El
Removal and/or Held
and/or Address
I.:., Hold SARATOGA NATIONAL
CD Date Point of CEMETERY
a.• ❑Transportation Shipment
t by Common Destination
15 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
I_ Remains are Shipped, If Other than Above
2 Address
IX
lal
" Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued q- 7 -14 Registrar of Vital Statistics qu f ni,Q . atom/
(signature)
District Number /-15622.. Place J31 QEyNot,)-s R.D. t'/O/Z LI /v y h 'c2S
F- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 09/05/2014 Place of Disposition Quaker Road Queensbury,NY 12804
M', (address)
Ui
Cl, (section) /� (lot number (grave number)
O Name of Sexton or Person in Charge of Premises
{�s� �� '''
/�
(please print)
LIJ ��J Signature `-4 ,4-- Title mWt.
(over)
DOH-1555 (02/2004)