Flores, Sylvester It
NEW YORK STATE DEPARTMENT OF HEALTH s '`y (O
Vital Records Section Burial - Transit Permit
Name Fir t Middle Last Se
r Sylvester John ores Male
Date of Death Age If Veteran of U.S. Armed Forces,
02124/2013 72 years War or Dates
1: Place of Death Hospital, Institution or
Z City, AINAYorMWENg16 Saratoga Springs Street Address Saratoga Hospital
aManner of Death 0 Natural Cause 0 Accident El Homicide 0 Suicide El Undetermined ri Pending
tii Circumstances Investigation
W Medical Certifier Name Title
Rodney Ying MD
Address
59 Myrtle Street Saratoga Springs, Ny
Death Certificate Filed District Number Register Number
City, VONA-XoNi143414 Saratoga Springs 4501 106
ElBurial Date Cemetery or Crematory
03/04/2013 Pine View Crematory
['Entombment Address
+E]Cremation Queensbury N Y .
Date Place Removed
Z❑Removal and/or Held
and/or Address
I= Hold
IV)
0 Date Point of
Transportation Shipment
co
d by Common Destination
Carrier
Q Disinterment Date Cemetery Address
:.:> Reinterment Date Cemetery Address
Permit Issued to Registration28 Number
Name of Funeral Home .Carleton Funeral Home, Inc. 000
Address
68 Main St,-Po Box 67, Hudson Falls, Ny 12839
Name of Funeral Firm Making Disposition or to Whom
F Remains are Shipped, If Other than Above
Z Address
Iu
P` Permission is hereby granted to dispose of the human remain crib d abow a "ndicate
Date issued 02/26/2013 Registrar of Vital Statistics 1'
(signature)
iN District Number 4501 Place Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition AI Place of Disposition jttiJ Cr �drio-
Ili (II i61� (address)
MO(4
i'3
CC (section) ' (lot number) (grave number)
1
i Name of Sexton or Person in Char•!- of Premises it'
S���
<rt!► , ( lease print)
Signature4 la t Title 4. w-o`
(over)
DOH-1555 (02/2004) •