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Henderson, Joseph li to NEW YORK STATE DEPARTMENT OF HEALTH tii Vital Records Section Burial - Transit Permit Name First Middle • Last Sex Joseph Henderson Male Date of Death Age If Veteran of U.S. Armed Forces, August 17, 2013 50 War or Dates Place of Dea . - Hospital, Institution or uj City, Town o Ilage Hudson Falls Street Address 5 Combs Ave. Ci Manner of Death © Natural Cause El Accident ❑ Homicide 0 Suicide ❑ Undetermined ❑ Pending W Circumstances Investigation W Medical Certifier Name Title C Erick Pillemer, M.D. Dr. Address 102 Park Street Glens Falls, NY 12801 Death Certificate Filed District Number Register Number City, Town or Village v£ila Co /t) ❑Burial Date Cemetery or Crematory August 19, 2013 Pine View Crematorium ❑Entombment Address ®Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z ❑ Removal and/or Held 0and/or Address E Hold Union Cemetery Date Point of ❑Transportation Shipment by Common Destination 1; Carrier Date Cemetery Address ❑ Disinterment Date Cemetery Address ID 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 h Remains are Shipped, If Other than Above 2 Address it W;,, 0.- Permission is hereby granted to dispose of the human remains described above asindicated. Date Issued 8 _ 19- /3 Registrar of Vital Statistics ty)044`//- (signature) District Number 6-/d t", Place /j ju.,467, 40-44 , / L1 ▪ I certify that the remains of the decedent identified above were disposed of in a ccordancewith this permit on: w' Date of Disposition 41110113 Place of Disposition C fidr . L (address) W W (section) AA) (lot number) C (grave number) O Name of Sexton or Perso in Charge�����f Premiseslh/lt ci,K ( ease print) W Signature .--� Title Cage)ftlDd (over) DOH-1555 (02/2004)