Fish, Wayne NEW YORK STATE DEPARTMENT OF HEALTH ± c-71
Vital Records Section _ Burial - Transit Per it
Name First Middle Last Sex
Wayne John Fish Male
Date of Death Age If Veteran of U.S. Armed Forces,
May 18, 2013 54 War or Dates
Place of Death Hospital, Institution or
w City, Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death iLulvl Natural Cause ❑ Accident ❑ Homicide 0 Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
C . Rajre Sadal, M.D
Address
2 Broad Street Plaza Glens Falls, NY 12801
Death Certificate Filed District Number ` 1 Register Number
City, Town or Village b 0
❑Burial ' Date Cemetery or Crematory
May 20, 2013 Pine View Crematorium
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z f-1 Re
moval and/or Held
l and/or Address
H! Hold
CO Date Point of
p„ ❑Transportation Shipment
(I) by Common Destination
O Carrier _
Date Cemetery Address
El Disinterment
Date Cemetery Address
El 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
I— Remains are Shipped, If Other than Above
2` Address
W
0" Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 5 /z Q `13 Registrar of Vital Statistics W CM"Y`Q- l/`)
/ (signature)
District Number 5 0 ( Place 6 cQi.S �a /`�1\5 ( l
• I certify that the remains of the decedent identified above were disposed of in accordance� p with
/this
�permit on:
w Date of Disposition c'2-) • )3 Place of Disposition pt,'.11- \ p... ,0 �'v" `"`"
2 (address)
W
(section) /� _ t nu er) (grave number)
O Name of Sexto► o •er.an in Charge of Premises ��--'O t'" ift1 �
z, t))
W Signatur=��� � (please print
Title C_ I1 6 ! '5 f
(over)
DOH-1555 (02/2004)