Havens, John NEW YORK STATE DEPARTMENT OF HEALTH rt 70
Vital Records Section e Burial - Transit Permit
AA Name First Middle Last Sex
John Ewing Havens Male
33' Date of Death Age If Veteran of U.S. Armed Forces,
November 23, 2014 64 War or Dates
1-4 Place of Death Hospital, Institution or
tu:' City, Town or Village Glens Falls Street Address Glens Falls Hospital
�' Manner of Death j Natural Cause El Accident Homicide 0 Suicide Undetermined Pending
,ti Circumstances Investigation
ivt Medical Certifier Name Title
i; A.eel Gillani, M.D. Dr.
r Address
100 Park Street P ne Pavillian Glens Falls, NY 12801
lti Death Certificate Filed District Number Register.Number
City, Town or Village 5601 j t/0
`0 Burial Date Cemetery or Crematory
November 25, 2014 Pine View Crematorium
1'❑Entombment Address
:®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
,1, Hold
N Date Point of
❑Transportation Shipment
° ' by Common Destination
'4 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
Remains are Shipped, If Other than Above
Address
WE
zr" Permission is he eby granted to dispose of the human remains de ribed abo�� �„ e as indi ated.
s Date Issued Registrar of Vital Statistics '`-(
(signature)
District Number 5601 Place F /7
N„
certify that the remains of the decedent identified above were disposed of in accordance wit this permit on:
W Date of Disposition 11/25/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
W_':
0
; (section) (lot number) `i (grave number)
:0-: Name of Sexton or Person in Charge of Premises tnstirliv- Jrarw4F
1 (please print)
Signature /1Title (401tiat
(over)
DOH-1555 (02/2004)