WAite, George NEW YORK STATE DEPARTMENT OF HEALTH r ZI
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
George Milford Waite Male
Date of Death Age If Veteran of U.S. Armed Forces,
April 11, 2013 87 War or Dates World War II
Place of Death Hospital, Institution or
W City, Town or Village Argyle Street Address PLEASANT VALLEY NURSING FAC.
Ci Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide 0 Suicide 0 Undetermined El 1--I Pending
LU
CircumstancesInvestigation
WW Medical Certifier Name Title
Barney Rubenstein MD,
Address
51 South Union St. Cambridge, NY 12816
Death Certificate Filed District Number - --, . \ Register Number,,
City, Town or Village U j
❑Burial Date Cemetery or Crematory
April 15, 2013 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
• and/or Address
p Hold
5 Date Point of
a ❑Transportation Shipment
f/) by Common Destination
CI Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
El 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
L Remains are Shipped, If Other than Above
2 Address
W'
a Permission is hereby granted to dispose of the human re ins described above as indicated.
Date Issued Lb/j�I�� Registrar of Vital Statistics ()__0 Q 1 (J J\A'l7
(signature)
District Number 699._ Place [ a cps__
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W;' Date of Disposition N-l619 Place of Disposition 'FAO ( tjt'--
e (address)
WGO
W (section) lot number) (grave number)
dName of Sexton or Person in Charge o Premises ( 1 — comfit
Z (pleas print)
W Signature 74L_ Title CEC:A)134L
(over)
DOH-1555 (02/2004)