Carey, Francis NEW YORK STATE DEPARTMENT OF HEALTH t7 L X
Vital Records Section t' . , Burial - ransit Permit
Name First Middle Last Sex
Francis Robert Carey Male
Date of Death Age If Veteran of U.S. Armed Forces,
April 18, 2013 71 War or Dates
▪ Place of Death Hospital, Institution or
u1 City, Town or Village Queensbury Street Address The Stanton Nursing & Rehab. Center
W Manner of Death u Natural Cause ❑ Accident 0 Homicide 0 Suicide ❑ Undetermined ❑ Pending
W Circumstances Investigation
W Medical Certifier Name Title
0' Roslyn Socolof_MD,
Address
100 Broad St Plaza Glens Falls, NY 12801
CiticVll Filed Distli� Number-) R CD Number
Cite_ae,
own o Village '�
❑Buria Date Cemetery or Crematory
April 19, 2013 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
7.
Date Place Removed
z ❑ Removal and/or Held
and/or Address
p Hold_
CO Date Point of
d ❑Transportation Shipment
(/ by Common Destination
0- Carrier
Date Cemetery Address
❑ Disinterment
I: Date 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
Cr
W'
L3. Permission is hereb granted to dispose of the human ains described ab p r� me as indicated.
Date Issued 4�� Registrar of Vital Statistics
(signature)
District Number . `") Place / Ct-r, O'r Lk 5L,
I certify that the remains of the decedent identified above were disposed of in ccordanc with this permit on:
I—
Z Date of Disposition 4-1213 Place of Disposition ,
X (address)
LU
co
re (section) /7 (lot number) (grave number)
0• Name of Sexton or Pe on in Charg of Premises r,, o
Z (please print)
W Signature Title adEMATOil
(over)
DOH-1555 (02/2004)