Genier, Milford 7
NEW YORK STATE DEPARTMENT OF HEALTH Jy�
Vital Records Section Burial - Transit Permit
s Name First Middle Last Sex
Milford Anthony Genier Male
Date of Death Age If Veteran of U.S. Armed Forces,
December 21, 2014 81 War or Dates
F' Place of Death Hospital, Institution or
.0 City, Town or Village Queensbury Street Address 31 Woodland Path
Manner of Death[] Natural Cause 0 Accident 0 Homicide Ei Suicide ❑Undetermined ❑ Pending
lit
Circumstances Investigation
W: Medical Certifier Name Title
a John Sawyer, MD,
Address
R 453 Dixon Rd Queensbury, NY 12804
* Peat ertificate Filed District Number Register Number
Cit , Town o Village C C.AS2 v jv1 'SLt2c n 1—70
0 Burial Date Cemetery or Crematory
December 23, 2014 (--, Pine View Crematorium
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
Removal and/or Held
5 and/or Address
Hold
0 Date Point of
Transportation Shipment
Vi�.;❑
by Common Destination
. 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
,7:7:rz
Name of Funeral Firm Making Disposition or to Whom
om_ Remains are Shipped, If Other than Above
: Address
•
tit
II" Permission is hereby granted to dispose of the human re sins describe -ab ve as indicated.
._ Date Issued Registrar of Vital Statistics
Q , n
(signature)
District Numbe&g c r) Place 0 \ a f- 0 -r, 1
7:17 I certify that the remains of the decedent identified above were disposed of in acc ce with this permit on:
-a
Date of Disposition 12/23/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
Ait
(section) it numbe (grave number)
3>
• Name of Sexton or Person in Charge of Premises (p/eate print)
Ui` Signature Title 4 = l
(over)
DOH-1555 (02/2004)