Rivers, Arthur NEW YORK STATE DEPARTMENT OF HEALTH r s 41 3'S
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Arthur John Rivers Male
Date of Death Age If Veteran of U.S. Armed Forces,
July 7, 2013 74 War or Dates
i— P4" e of Death Hospital,institution or
WTown or Village Glens Falls Street Address Glens Falls Hospital
w` Manner of Death .] Natural Cause Accident Homicide n Suicide Undetermined Pending
t? Circumstances Investigation
WW Medical Certifier Name Title
Robert Evans,
Address
One Irongate Center Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village S 6 0 / ,Z cd 5
❑Burial Date Cemetery or Crematory
July 12, 2013 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z Fl Removal and/or Held
0 and/or Address
F Hold
n Date Point of
01. I 1 Transportation Shipment
_ by Common Destination
Carrier
Date Cemetery Address
I I Disinterment
___ Reinterment 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
l Remains are Shipped, If Other than Above
2 Address
LX
W`
il. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 7) t 0 ) L3 Registrar of Vital Statistics LA)c_A ,vqz t.A)(signature
District Number 56 0 ( Place 4(szA,-.5, R . i t S / N T
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
�w Date of Dis osition r '� DispositionCT
p �— ,Z 3 Place of ����t „� c�,�� �„�
in (address)
ft`' (section) (lot number) (grave number)
0 p Name of Sexton or Pe on in Cha a of Premises[w ick./ 61.0..eU(
z ._ (please print)
W Signature Title Cl
(over)
DOH-1555 (02/2004)