Beckwith, Michael NEW YORK STATE DEPARTMENT OF HEALT'�i Burial - Transit
Vital Records Section Permit
Name First Middle Last Sex
Michael Stuart Beckwith Male
_- Date of Death Age If Veteran of U.S.Armed Forces,
a January 28, 2014 71 War or Dates
}- Place of Death Hospital, Institution or
Ili Z_ City, Town or Village Glens Falls Street Address Glens Falls Hospital
CI' Manner of Death a Natural Cause 0 Accident Homicide D Suicide Undetermined Pending
lii Circumstanhes Investigation
W° Medical Certifier Name Title
CI
Address
Death Certificate Filed District Number ``�� Register mber
City, Town or Village (al�
❑Burial Date Cemetery or Crematory
January 31, 2014 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
Removal and/or Held
fj and/or Address
H Hold
Date Point of
i ❑Q. Transportation _ Shipment
CD by Common Destination
a' 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
J-- Remains are Shipped, If Other than Above
2 Address
W
0- Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued l f 3 i 1 it--I it--I Registrar of Vital Statistics W Ck k-A)-Ai'tel1/452P
(signature)
District Number ,/ Place 6/Fl,1fir//S7 /0/ /0)g0/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition 01/31/2014 Place of Disposition Quaker Road Queensbury,NY 12804
W (address)
W
' (section) I (lot number)r (grave number)
Ca Name of Sexton or Person ' Charge of P emises � r 3
hat
Z Tease print)
Ili Signature Title aftvtt
(over)
DOH-1555 (02/2004)