Bey, Makhayil NEW YORK STATE DEPARTMENT OF HEALTNi !m. tt/
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Makhayil Abdullah Bey Male
Date of Death Age If Veteran of U.S. Armed Forces,
March 9, 2013 43 War or Dates
ZPlace of Death Hospital, Institution or
w City, Town or Village Fort Ann Street Address 11601 State Route 22
Ci Manner of Death❑ Natural Cause ❑ Accident ❑ Homicide El Suicide El Undetermined ❑ Pending
C.) Circumstances Investigation
W Medical Certifier Name Title
CI Max Grossman MD,
Address
North St. Granville, NY 12832
Death Certificate Filed District Number Register Number
City, Town or Village
❑Burial Date Cemetery or Crematory
March 21, 2013 Pine View Crematorium
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
i- Hold
CO Date Point of
eL ❑Transportation Shipment
_> by Common Destination
0 Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ 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
Address
cr
a' Permission is h reby ranted to dispose of the human re. ins described above a/ in;;_..
Date Issued 3 l ) ,: Registrar of Vital Statistics _ �. __� _,,/ , _ _ ,'
signature)
District Number ' Place / 04..-r..._ l2-F 2 7
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Imo.
t Date of Disposition 1-Lis I 3 Place of Disposition Pt N(- \J, ire d�Y
m (address)
W
� (section) �� � (je(ynum�r) d (grave number)
e Name of Sexton or ers in%,.rge of Premises �jf�/� /h�►
Z ,I � (please print) �
W Signature 72" Title �- e- 4 �l 6- 1 (over)
DOH-1555 (02/2004)