Walrath, Edward NEW YORK STATE DEPARTMENT OF HEALTH -11
Vital Records Section - ,�
Burial - Transit Permit
1 Name First Middle Last Sex
Edward Lewis Walrath Male
Date of Death Age �7 If Veteran of U.S. Armed Forces,
September 14, 2013 / D War or Dates i q 5 `) - 1 `l Ca 0
I- Place of Death Hospital, Institution or
W City, Town or Village Street Address
CI Manner of Death rvl
Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined El 1--I Pending
WLill
0CircumstancesInvestigation
W Medical Certifier Name Title
W
Philip Gara, M.D. Dr.
Address
Broadway Fort Edward, NY 12828
Deat ificate Filed ff District Number Register Number
Cit Town r Village t�i ( 5 S. h(iv-557 a, l G
❑Burial Date J Cemetery or Crematory
September 17, 2013 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
O and/or Address
E Hold
CO Date Point of
a ❑Transportation Shipment
0) by Common Destination
p 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
I— Remains are Shipped, If Other than Above
Address
Ce
il Permission is hereby granted to dispose of the human re ins described above as indicated.
Date Issued Q-/7 20/3 Registrar of Vital Statistics , ( QQ , :-Q--�
(signature)
District Number 5762 Place �pt4,-,-_cam k r�5ro
1
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition ` l i$I13 Place of Disposition gcV A.) rvefort.---
M.` (address)
W
CC (section) t number) (grave number)
ck Name of Sexton or Person i Charge o Premises Nait
ck Z (plea n� se print)
MR
W Signature Title CiPk 14
(over)
DOH-1555 (02/2004)