Welch, Gary NEW YORK STATE DEPARTMENT OF HEALTH it 5
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Gary Francis Welch Male
Date of Death Age If Veteran of U.S. Armed Forces,
December 30, 2012 69 War or Dates
F" Place of Death Hospital, Institution or
WCity, Town or Village Queensbury Street Address The Stanton Nursing & Rehab. Center
111 Manner of Death X❑ Natural Cause ❑ Accident ElHomicide El Suicide 0 Undetermined pi Pending
Circumstances Investigation
W Medical Certifier Name Title
CI Suzanne Blood, M.D. Dr.
Address
14 Manor Drive Queensbury, NY 12804
Deat ificate File trict Number Register Number
Cit Tow Village (9 f CO Li
❑Burial Date �Q/ ' Cemetery or Crematory
January 2, 2013 v Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z El Removal I and/or Held
u and/or Address
F., Hold
N Date Point of
a0 Transportation Shipment
by Common Destination
13 Carrier
111 Disinterment Date Cemetery Address
EjReinterment 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
I Remains are Shipped, If Other than Above
2 Address
W
CL Permission is hereby granted to dispose of the human r mains described abo a as indicated.
Date Issued 1 ( Z., (r4013 Registrar of Vital Statisti� . a
(signature)
District NumbeCoc ) Place 0 cy(-N CD-f n ln.`Q--e.nsh--1
I certify that the remains of the decedent identified above were disposed of in acco an a with this permit on:
Lij• Date of Disposition 1-1-k3 Place of Disposition �U.Lv./ Cr Qrlvti
2 (address)
Ill
CO
Ce (section) d (lot number) (grave number)
pName of Sexton or Person in Charge of Premises ati, Sum
Z (:re print)
W Signature /4(..-- �-- Title G1Lremih-c-4_,
(over)
DOH-1555 (02/2004)