Weaver, Winfield NEW YORK STATE DEPARTMENT OF HEALTfi it Lill
Vital Records Section Burial - Transit Permit
Name First r Middle Last Sex
Wftflt3itt \4•„rY Clinton Weaver Male
Date of Death Age If Veteran of U.S. Armed Forces,
August 14, 2013 82 War or Dates
• Place of Death Hospital, Institution or
w City, Town or Village Kingsbury Street Address 150 Dean Road
W Manner of Death rrl
L..Li Natural Cause 0 Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
LI Circumstances Investigation
W Medical Certifier Name Title
a Ageel Gillanni,
Address
102 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village 5 76 a Jo
❑Burial Date Cemetery or Crematory
August 16, 2013 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
O and/or Address
F..° Hold
4 Date Point of
a ❑Transportation Shipment
tt) by Common Destination
0 Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Reinterment
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
Remains are Shipped, If Other than Above
2 Address
W
a., Permission is hereby granted to dispose of the human remai escribed above as indicated.
Date Issued o"l()„.ad r 3 Registrar of Vital Statistics ��� o. C,�
(signature)
District Number 57k, Place 7 ,�
1 /
FI certify that the remains of the decedent identified bove were disposed of in accordance with this permit on:
a
W Date of Disposition giii(i3 Place of Disposition 2�IV�,/ ioru .,
(address)
W
C (section) (lot number) (grave number)
O Aft s StaubStauba Name of Sexton or Person • Charge of Pr mises
Z (p ase print)
W Signature - Title
(over)
DOH-1555 (02/2004)