Myers, Kaleb NEW YORK STATE DEPARTMENT OF HEALTH 4 �6
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Kaleb Ev2n Myers Male
Date of Death Age If Veteran of U.S. Armed Forces,
December 12, 2012 () War or Dates
i— Place of Death Hospital, Institution or
W City, Town or Village Glens Falls Street Address Glens Falls Hospital
WManner of Death❑ Natural Cause ElAccident ❑ Homicide ElSuicide ❑ Undetermined ❑ Pending
ii Circumstances Investigation
W Medical Certifier Name Title
CI Patricia Snyder, M.D. Dr.
Address
45 Hudson Ave. Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village 5 6 0 ! F 0
❑Burial Date Cemetery or Crematory
December 14, 2012 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
F. Hold
CO Date Point of
0�. ❑Transportation Shipment
Cl) by Common Destination
t] Carrier
Date Cemetery Address
El Disinterment
Date Cemetery Address
El 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
Remains are Shipped, If Other than Above
2: Address
CC
W''
>L1. Permission is hereby granted to dispose of the human remains described above as inidicated.
Date Issued r Z-/ 1y/20) Registrar of Vital Statistics (),)c
(signature)
District Number 60 f Place 6 (s1--S r 1,1 J ) ivy
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition ii..-(%-a_ Place of Disposition e,KV,&id Lre,„4 rtu,.
2 (address)
WCO
Ce (section) /(lot number) c_ (grave number)
pName of Sexton or Person in Charg of Premises tr'Als r .. ematt
Z ii (p/ee print)
W, Signature 41...— Title Cei+Mfi-i
(over)
DOH-1555 (02/2004)