Carpenter III, Gary NEW YORK STATE DEPARTMENT OF HEALTH B
Vital Records Section Burial - Transi @ mlt
Name First Middle Last Sex
Gary S. Carpenter III Male
Date of Death Age If Veteran of U.S.Armed Forces,
11/16/2012 5 War or Dates No
E— Place of Death Hospital, Institution
W City ,Town or Village City of Albany or Street Address Albany Medical Center Hospital
p' Manner of Death Natural ElUndetermined ❑ Pending
W ❑ Cause ❑ Accident i Homicide El Suicide
Circumstances Investigation
U' Medical Certifier Name Title
pTimothy Cavanaugh Coroner
Address
112 State Street Albany, NY 12207
Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 2187
Date Cemetery or Crematory
❑ Burial 11/28/2012 Pineview Crematorium.
❑ Entombment Address
® Cremation Queensbury, NY
Date Place Removed
Z Removal and/or Held
2 ❑ and/or Address
H Hold
CO
0 Date Point of
CL Transportation Shipment
Cl)' ❑ By Common
CI Carrier Destination
III Disinterment
Cemetery Address
Disinterment
❑ Date Cemetery Address
Reinterment
Permit Issued To Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00291
Address
68 Main Street Hudson Falls, NY 12839
— Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2' Address
W'
- Permission is hereby granted to dispose of the human remains described above as indicated
Date 11/23/2012 Registrar of Vital Statistics D �• 9 JoL
Issued (signature)
District Number 101 Place City of Albany, NY (((///
I certify that the remains of the decedent identified above were
rene disposed of inraccordance with this permit on:
Z''', Date of Disposition //'g,Iz Place of Disposition U'�n/, i�/ ��e.e..,..,„ Y1.�
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(section) (lot number) (grave number)
W° Name of Sexton or erson in Charge of Premises �� ti t/'1o.,✓/i/w, el
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Signature Title ��'��'� A/�'�0 !/kr-
(over)
DOH-1555 (02/2004)