Weller, Hally NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Hally E. Weller Male
Date of Death Age If Veteran of U.S. Armed Forces,
September 27, 2013 93 War or Dates
1- Place of Death Hospital, Institution or
Z City, Town or Village Wilton Street Address Home Of The Good Shepard
pManner of Death 0 Natural Cause ❑Accident El Homicide ❑Suicide ❑Undetermined ❑Pending
W Circumstances Investigation
W Medical Certifier Name Title
G Dr.Coppens
Address
,Glens Falls,NY 12801
Death Certificate Filed District Number //// Register yum er
City,Town or Village Wilton Y`�//l�a9
❑Burial Date Cemetery or Crematory
October 1,2013 Pine View Crematory
Address
®Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
• and/or Address
H Hold
Q Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
['Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
i- Remains are Shipped, If Other than Above
E Address
W
W
a. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 9(rd Registrar of Vital Statistics �`/ ,6r 1
(signatur@)
District Number �/.�'/ Place Wilton
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition IO/i 10 Place of Disposition Zetkv., i�rwttir1.—.
2 (address)
W
CO
re (section) A,;4(lot,number) (grave number)
,...c.i...01.
p Name of Sexton or Person in Charge of Premises Z 42:
(ease print)
W
SignatureTitle Ci1kt PWTJ IL-
(over)
DOH-1555(02/2004)