Day Sr, Dwight ftsu1
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
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Name First Middle Last Sex
Dwight D. Day Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
August 24, 2014 51 War or Dates
Place of Death Hospital, Institution or
W` City, Town or Village Glens Falls Street Address Glens Falls Hospital
WManner of Death 171 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined El❑ Pending
o Circumstances Investigation
WW Medical Certifier Name Title
CI James North, M.D
Address
100 Broad St. Glens Falls, NY 12801
Death Certificate Filed District Num � Register Nupper
City, Town or Village ii4 7
0 Burial Date Cemetery or Crematory
August 27, 2014 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
F Hold
0 Date Point of
an ❑Transportation Shipment
N by Common Destination
a Carrier
[' Disinterment Date Cemetery Address
Date Cemetery Address
❑ 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
t Remains are Shipped, If Other than Above
2 Address
111
C" Permission is hereby granted to dispose of the human remats descri ed above ass indicated
Date Issued p�1a� aC7� Registrar of Vital Statistics d QZ_.‘2 a7, "ii e'),‘---
/ (slnature)g
District Number 5Coo / Place .-.L.:, CLP '7/ y
I certify that the remains of the decedent identified above were disposed of in accordance with this/permit on:
W;, Date of Disposition 08/27/2014 Place of Disposition Quaker Road Queensbury,NY 12804
2 (address)
W'±
I (section) (lot number) (grave number)
Ci Name of Sexton or Person in Charge of Premises A,,,t,..._ S,""to
z (p/ se print)
Signature �� L Title CtreMiTiO ,
(over)
DOH-1555 (02/2004)