Weeks, Miles NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Perim it
Name First Middle Last Sex
Miles Hamilton Weeks Male
Date of Death Age If Veteran of U.S. Armed Forces,
07/10/2013 89 years War or Dates WW II
Place of Death Hospital, Institution or
CityIli , TowX9Ci1ED�CX Glens Falls Street Address Glens Falls Hospital
• Manner of Death }1 Iatural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Iti Circumstances Investigation
W Medical Certifier Name Title
CI Amy Hogam- Moulton M. D.
Address
102 Park Street Glens Falls, N Y 12801
Death Certificate Filed District Number Register Number
City, TowDAMitillGeXX Glens Falls 5601 292
❑Burial Date Cemetery or Crematory
['Entombment Address
Pine View Crematorium
Address
l ic�remation Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
9 ❑and/or
F= Hold Address
Cl)
O Date Point of
EL 1-1
Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D. Baker Funeral Home 01130
Address
11 Lafayette Street Queensbury, N Y 12804 •
Name of Funeral Firm Making Disposition or to Whom
I . Remains are Shipped, If Other than Above
2 Address
CC
tit
'" Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/12/2013 Registrar of Vital Statistics W
(signatur
District Number 5501 Place Glens Falls Ni y
)
'' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
ILI Date of Disposition 7-1 c(3 Place of Disposition 1, (mice;`
2 (address)
Lu
tfl
{C (section) (lot nubgr) (grave number)
O Name of Sexton or Person i Charge of Premises //'t,tli—
(please p
W.
Signature ta-- Titlek-Mnic12
1..�" (over)
•
DOH-1555 (02/2004)