Bartlett, Dennis NEW YORK STATE DEPARTMENT OF HEALTH it (,
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Dennis Michael Bartlett Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 20, 2012 63 War or Dates Vietnam
PI-ce of Death Hospital, Institution or
la 40Town or Village Glens Falls Street Address Glens Falls Hospital
anner of Death m.i Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
!C Erick Pillemer, M.D. Dr.
Address
102 Park Street Glens Falls, NY 12801
D th Certificate Filed District Number Register Number
City)Town or Village w/p�,3 /Z/L 5601 j32
urial Date Cemetery or Crematory
November 23, 2012 Pine Vew Crematorium
U Entombment Address
®Cremation Queensbury,NY 12804
Date Place Removed
; . ❑ Removal and/or Held
{ and/or Address
p Hold
Date Point of
eL ❑ Transportation Shipment
by Common Destination
0 Carrier
Date Cemetery Address
❑ Disinterment
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
,7 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
W
Ci"'". Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued j i / 23 / j Z Registrar of Vital Statistics (.CA.A,4,�Q
(signature)
District Number 5601 Place ‘740/45 /75 /a his/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ru Date of Disposition U/24/IL Place of Disposition -ZAdli«., Cr itdrw*
E (address)
W
CO
W (section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of Pre ises ��' .^��
(p/ se print)
LU Signature C Title CecoRi0i
(over)
DOH-1555 (02/2004)