Barker, William Sll
NEW YORK STATE DEPARTMENT OF HEALTH `+t" 7
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
William Henry Barker Male
+ Date of Death Age If Veteran of U.S. Armed Forces,
1 ' May 15, 2012 83 War or Dates ,kPS
I— PI ce of Death Hospital, Institution or
rri City) Town or Village 6/ j Ai/S, AV Street Address 6�� s JCf lS/ Ny
W Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ri❑ Pending
[LiCircumstances Investigation
W Medical Certifier Name Title
C Diane MacDonnell MD,
Address
1 West Ave. Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village c5-67e/ v
❑Burial Date Cemetery or Crematory
May 16, 2012 Pine View Crematorium
❑Entombment Address
'` ,, ®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
p Hold
0' Date Point of
p, ❑Transportation Shipment
CO by Common Destination
CI Carrier
Date Cemetery Address
❑ 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
I— Remains are Shipped, If Other than Above
2 Address
W
d Permission is here y granted to dispose of the human remains desc ed a ov s i • ed.
Date Issued ®s/o 20(2-Registrar of Vital Statistics � 6�`
//_ // (signature)
District Number 5O ��- /, 74'/ Place (v 4)7/
F- I certify that the remains of the decedent identified above were disposed of
in accordance with this permit on:
wDate of Disposition S r I it Place of Disposition .P,j V RV Cry ellr,l--
(address)
W
te (section) 4 (lot number) (grave number)
0 Name of Sexton or Pers n in Charge Premises 1'0) , S",4tt-
z
(please print)
W- Signature s Title OlkivITROIL
(over)
DOH-1555 (02/2004)