Gavita, Joseph NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Joseph Anthony Gavita Male
Date of Death Age If Veteran of U.S. Armed Forces,
December 25, 2013 90 War or Dates World War II
Place of Death Hospital, Institution or
al City, Town or Village Glens Falls Street Address Glens Falls Hospital
Cr Manner of Death Natural Cause El Accident ❑Homicide ❑ Suicide Li Undetermined ❑ Pending
W' Circumstances Investigation
C
G' Medical Certifier Name Title
Thomas Hafer, M.D. Dr.
Address
9 Carey Road Queensbury, NY 12804
Death Certificate Filed District Number Register Number
City, Town or Village C)1 5693
❑Burial Date Cemetery or Crematory
F 12/27/2013 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
_E Hold St. Mary's Cemetery In Sgf
CA Date Point of
,,. ❑Transportation Shipment
the by Common Destination
D Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ 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
Remains are Shipped, If Other than Above
• Address
Cr
a.- Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued i• / 2.-7 1� Registrar of Vital Statistics N`fin ,�....Af•A
(signature)
District Number gA01 Place 6 ()Q_AIN.,s, po, 1, l j l.I'
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W. Date of Disposition Place of Disposition
Z (address)
LW
W (section) (lot number) (grave number)
a: Name of Sexton or Person in Charge of Premises
.Z (please print)
W Signature Title
(over)
DOH-1555 (02/2004)