Coso, Howard NEW YORK STATE DEPARTMENT OF HEALTH 41 603 L
Vital Records Section f 1. Burial - Transit Permit
' Name First Middle Last Sex
Howard George Coso Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 7, 2014 88 War or Dates
Place of Death Hospital, Institution or
WH City, Town or Village Fort Edward Street Address FORT HUDSON HEALTH CARE FAC.
CI W Manner of Death X❑ Natural Cause ❑ Accident El Homicide n Suicide [II Undetermined ❑ Pending
Circumstances Investigation
W' Medical Certifier Name Title
W
Bernardo R Villajuan MD,
Address
161 Carey Road Queensbury, NY 12804
Death Certificate Filed Distric u,r ,er Register iVuer
City, Town or Village0.0..D (p
❑Burial Date Cemetery or Crematory
October 7, 2014 Pine Vew Crematorium
❑Entombment Address
®Cremation Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
F Hold ST. PETERS/sT. PAUL'S
CO Date Point of CEMETERY
a. ❑ Transportation Shipment
CO by Common Destination
8 Carrier
Date Cemetery Address
El Disinterment
Date Cemetery Address
El 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
I— Remains are Shipped, If Other than Above
2 Address
W
EL Permission is he
he eb grant d to dispose of the human r n described a ove in is ted.
Date Issued 1� Registrar of Vital Statistics V `
/ (signature)
/
District NumberS135 Place I (j(,i` ( 1J ‘y ! r (r�
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition 10/07/2014 Place of Disposition Queensbury,NY 12804
(address)
W
CO
IX (section) yy (lot number (grave number)
pName of Sexton or Person in Charge of Premises l4n,fpt,� ai^tbt
(please print)
,I�
W Signature �� � Title Ccfci►Iryt d
(over)
DOH-1555 (02/2004)