Albrecht, Ernest NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit 137
Name First Middle Last Sex
Ernest R Albrecht Male
Date of Death Age If Veteran of U.S. Armed Forces,
March 7, 2012 81 War or Dates
Place of Death Hospital, Institution or
iiiCity, Town or Village Glens Falls Street Address Glens Falls Hospital
W' Manner of Death X❑ Natural Cause Accident El Homicide El Suicide Undetermined Pending
0 Circumstances Investigation
FL Medical Certifier Name Title
Frances Bollinger MD,
Address
161 Carey Rd Queensbury, NY 12804
Death Certificate Filed District Number Register Dumber
City, Town or Village 5601 11 er
❑Burial Date Cemetery or Crematory
March 8, 2012 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
_z ❑ Removal and/or Held
and/or Address
F. Hold
la
Date Point of
0 El Transportation Shipment
COby Common Destination
CI Carrier
Disinterment Date Cemetery Address
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
Address
Et
al
`=' Permission is hereby ranted to dispose of the human remains describ above a 'ndi
-}" a 08 2jj Registrar of Vital Statistics / ��,� ` �
Date Issued 3 v g
(signature)
District Number 5601 Place / 4. /4,/y iZ q0
F- I certify that the remains of the decedent identified above were disposed ofof in accordance,�` with this permit on:
WDate of Disposition time' li fait Place of Disposition FriOki° C0140r.
(address)
W (section) ` clot number)r (grave number)
0 Name of Sexton or P rson in Ch ge of Premises
t++
it
Z (please print)
W Signature Title C�'pm ipr�
(over)
DOH-1555 (02/2004)