Hammond, Walter NEW YORK STATE DEPARTMENT OF HEALTH # 752
Vital Records Section 4f i Burial - Transit Permit
- Name First Middle Last Sex
Walter Donald Hammond male
Date of Death Age If Veteran of U.S. Armed Forces,
December 3, 2013 79 War or Dates
1— Place of Death Hospital, Institution or
Ai, City, Town or Village Hudson Falls Street Address 158 Main St. Apt. 5
Manner of Death Natural Cause El Accident 0 Homicide El Suicide n Undetermined n Pending
Circumstances Investigation
L Medical Certifier Name Title
Michael Sikirica MD,
Address
50 Broad Street Waterford NY 12188
Death Certificate Filed District Number Register Number
COCity, Town or Village 7 a c ai
❑Burial Date Cemetery or Crematory
December 4, 2013 Pine View Crematorium
❑Entombment Address
N51ECremation Quaker Road Queensbury,NY 12804
Date Place Removed
` `ElRemoval and/or Held
and/or Address
' ' Hold
Date Point of
0 Transportation Shipment
by Common Destination
in Carrier
0 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
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human re ns scribed above as indicated.
Date Issued /a-ci- ao!3 Registrar of Vital Statistics "z 1,4)( t
(signature)
District Number 5 a, Place Ac-...., Za�Q—
z
I certify that the remains of the decedent identified ove were disposed of in accordance with this permit on:
M
Date of Disposition (Z-'1-h3 Place of Disposition 4;.7.4u,,,,, Cefreforn--
(address)
ir (section) of number) r (grave number)
13 Name of Sexton or Person ' Charge of emises AI JI nK14
W (pie e print)
Signature Title af M4wIR
(over)
DOH-1555 (02/2004)