Colton, Dalton NEW YORK STATE DEPARTMENT OF HEALTH I ri fi5
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Dalton James Colton Male
Date of Death Age If Veteran of U.S. Armed Forces,
April 1, 2013 i(5 4- War or Dates
ZPlace of Death Hospital, Institution or
W City, Town or Village Glens Falls Street Address Glens Falls Hospital
WManner of Death J Natural Cause El Accident 0 Homicide 0 Suicide Undetermined Pending
0Circumstances Investigation
W Medical Certifier Name Title
W
Edward Denious, M.D
Address
45 Hudson Ave. Glens Falls, NY 12801
Death Certificate Filed District Numm Register prrlber
City, Town or Village Y(�
❑Burial Date Cemetery or Crematory
April 4, 2013 Pine View Cemetery
❑Entombment Address
®Cremation Quaker Rd. Queensbury,NY 12804
Date Place Removed
z 1-1 Removal and/or Held
and/or Address
pi Hold
Date Point of
G. 0Transportation Shipment
0 by Common Destination
CI Carrier
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
I- Remains are Shipped, If Other than Above
2 Address
Ce
a Permission is hereby granted to dispose of the human remains described above a indicated.
Date Issued' /3 7 ii3 Registrar of Vital Statistics L J W
(signature)
District Number c bcl j Place 6 LQ v S rG l` s , NO ;)
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition y-Li-o Place of Disposition T.t��tw f e..,,.cibfun-
W (address)
IY (section) // (lot number) (grave number)
CI Name of Sexton or Pers in Charge of Pr mises / 11,l nwtF
1 ( lease print)
W Signature �" �. Title CCZr 14AiOt
(over)
DOH-1555 (02/2004)