Fish Jr, William NEW YORK STATE DEPARTMENT OF HEALTH 3g�
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
William Henry Fish Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
June 15, 2014 78 War or Dates
Place of Death Hospital, Institution or
w City, Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death X❑ Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined 1-1 Pending
CircumstancesInvestigation
W Medical Certifier Name Title
L"1` Michael Adams MD,
Address
Moreau Family Health Ctr S. Glens Falls, NY
Death Certificate Filed District Number Register 0ber
City, Town or Village
0 Burial Date Cemetery or Crematory
Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
• and/or Address
Hold
Date Point of
❑Transportation Shipment
N 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
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
2 Address
W.
tL Permission is h� reby granted to dispose of the human remains descr' e a ov s i ' ed.
Date Issued 6 Registrar of Vital Statistics
(signature)
District Number L60/ Place ./4/2f V. - ,&y /'`
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition lD (Pill Place of Disposition Quaker Road Queensbury,NY 12804
(address)
W
r4 (section) (I number) (grave number)
p• Name of Sexton or Person in Charge of Premises pry} `'"'
(please f print)
W Signature +`- Title 0I.fi•2101. de
(over)
DOH-1555 (02/2004)