Case, George r' , ,.„ 4 Icil
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
lEiiiii Name First Middle Last Sex
iig George R. Case Male
'.' Date of Death Age If Veteran of U.S. Armed Forces,
![ Apr 1 7 701 3 76 War or Dates 1 958-62
. Place of Death Hospital, Institution or
2 City, TovincioViibimecx Glens Falls Street Address Glens Falls Hospital
tii
ci Manner of Deathlatural Cause 0 Accident 0 Homicide 0 Suicide riUndetermined El Pending
Circumstances Investigation
ill Medical Certifier Name Title
EnsPph Mi h i ndu , MD
Address
_c1 pm Fa11s NY
Mii Death Certificate Filed District Number Registerer
IN CityxMA'AM Glens Falls 5601
' Date Cemetery or Crematory
ii ❑Burial April 4 , 2013 Pine View Crematorium
Address
®Cremation Tn of Oueensbury, NY
Date Place Removed
0❑Removal and/or Held
••" and/or Address
li Hold
0 Date Point of
N0 Transportation Shipment
C by Common Destination
Carrier
Disinterment Date Cemetery Address
:: Reinterment Date Cemetery Address
Permit Issued to .Registration Number
Name of Funeral Home Carleton Funeral Home, Inc 00281
Address
iiiiiiiii 68 Main St. , Hudson Falls, NY 12839
``i Name of Funeral Firm Making Disposition or to Whom
', Remains are Shipped, If Other than Above
Address
CL
iiii Permission is hereby granted to dispose of the human remains described above asrindicated.
Iii Date Issued L/ , 3 / Registrar of Vital Statistics LU h3---A,---ciskia
(signature)
€s< District Number 5601 Place City of Glens Falls, NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition (}1-11 Place of Disposition 4#14V0v C.rvy,. 1A k.
2 (address)
u:!
Cl)
CC (section) (lot number (grave number)
AName of Sexton or Person in Charge of Premises jji,r,),I Dehnilf
Z (please print)
W Signature ATitle Mai Oit
(over)
DOH-1555 (9/98)