DeCarli, Ernst if I
fi
NEW YORK STATE DEPARTMENT OF HEALTH #, G
Vital Records Section Burial - Transit Permit
n= Name First Middle Last Sex
Ernst DeCarli Male
;:: Date of Death Age If Veteran of U.S. Armed Forces,
t'= May 2,2014 91 War or Dates NA
1 i: Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
a Circumstances Investigation
jj1 Medical Certifier Name Title
t ] James North MD
Address
100 Broad Street,Glens Falls,NY 12801
., Death Certificate Filed District Number Register nnber
City, Town or Village Glens Falls 5601
❑Burial Date Cemetery or Crematory
Entombment May 5,2014 Pine View Crematory
Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
Cl)
0 Date Point of
N 1 'Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
::r.'"4$ Permit Issued to Registration Number
T Name of Funeral Home Alexander-Baker Funeral Home 00037
' Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
ik Remains are Shipped, If Other than Above
s-7 Address
J Permission is hereby granted to dispose of the humar 'emains scribed a ove as indic.ted.
Date Issued 5-5-14 Registrar of Vital Statistics i 01 p-, �\i! - 1 G
(signature)
:f; District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Z £ , .
W Date of Disposition 5�6�/� Place of Disposition „�,� ww K ,�.�
W (address)
CO
Ce (section) (lot number) (grave number)
p Name of Sexton or Person i Charge of Premises /ii,/�
Z ( lease print)
Signature 4Title Ca5iiinivst
(over)
DOH-1555 (02/2004)