Carpenter, Floyd NEW YORK STATE DEPARTMENT OF HEALTH 1tt
Vital Records Section Burial - Transit Permit
iiRi Name First Middle Last Sex
Floyd James Carpenter Male
Date of Death Age If Veteran of U.S. Armed Forces,
1 2-28-201 3 86 War or Dates Yes 1944-45
P4. Place of Death 11 Queensbury Place Hospital, Institution or
ZL City, Town or Village Street Address
0 Manner of Death®Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
til Circumstances Investigation
W Medical Cert. ier Name N Title
L ", -^ MD
161 Carey Roacgeueensbury, NY
Death Certificate Filed trictt Number Register Number
Ci Tn. of
ty, Town or Village Queensbury 1-1 �S
❑Burial Date Cemetery or Crematory
12-30-2013 Pine View Crematory
❑Entombment Address
®Cremation 21 Ouaker Road Oueenstzury, NY
Date Place Removed
Zni 1-1 Removal and/or Held
and/or Address
E Hold
0 Date Point of
tZ 0 Transportation Shipment _
0 by Common Destination
ni Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Re i(1g1stration Number
M. R.. Kilmer Funeral Home 078
Name of Funeral Home
iiiii Address
136 Main St. South (7;1anc Falls New York •
Name of Funeral Firm Making Disposition or to Whom
J . Remains are Shipped, If Other than Above
2 Address
i
III
CL
Permission is hereby granted to dispose of the human e ains described above as indicated.
Date Issued 1 2-3 0-1 3 Registrar of Vital Statistics Cam q . ("\--______ ,
(signature)
District Numbe (c'-) Place Tn. of Queensbury, NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
i
2
ili Date of Disposition is-iI rt3 Place of Disposition ?NU, i�,t....4ttiu`
(address)
l
f1
CC (section) 71 (lot mber) (grave number)
ct Name of Sexton or Person i Charge of Pre ises r.J r Je 644-
(pl se print)
Signature oeL Title Cilk OYL
(over)
DOH-1555 (02/2004)