Healy, John Ii it70 0
NEW YORK STATE DEPARTMENT OF HEALTH ''
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
John Francis Healy Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 9, 2014 78 War or Dates
Place,4fD ath Hospital, Institution or
w City,,Town r Village Fort Edward Street Address FORT HUDSON HEALTH CARE FAC.
W`` Manne Death Lu Natural Cause ❑ Accident ❑Homicide ❑ Suicide ❑ Undetermined ❑ Pending
U` Circumstances Investigation
W Medical Certifier Name Title
CI Daniel C Larson M.D.,
Address
9 Carey Road Queensbury, NY 12804
Death - .ificate Filed Distr r Regis r/Number
City own •r Village F02r EcL.9a-f ..
❑Bun- Date Cemetery or Crematory
November 12, 2014 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
p Hold
CO Date Point of
a. ❑Transportation Shipment
O by Common Destination
CD Carrier
Date Cemetery Address
El Disinterment
Date Cemetery Address
El 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
L; Remains are Shipped, If Other than Above
2 Address
it
W'
CL Permission is h reb granted to dispose of the human re ' s de; ribe abov as(' d' ated.
Date Issued Registrar of Vital Statistics `
(signature)
District Number E Place / �(�7L U l� C ) (,(
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 11/12/2014 Place of Disposition Quaker Road Queensbury,NY 12804
2 (address)
W
rf (section) (lot number) (grave number)
dName of Sexton or Person in Charge of Premises ante, Ailey
(please print)
LU Signature fr 44---- Title NkhtOW
(over)
DOH-1555 (02/2004)