Hazelton, William NEW YORK STATE DEPARTMENT OF HEALTH d Burial - Transit Permit
Vital Records Section ok
Name First Middle Last Sex
William Robert Hazelton Male
Date of Death Age If Veteran of U.S. Armed Forces,
08/24/2018 76 Years War or Dates 1962-1978
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
G Manner of Death®Natural Cause 0 Accident 0 Homicide 0 Suicide ri❑Undetermined Pending
W Circumstances Investigation
Lu Medical Certifier Name Title
9 Mathew Varughese DO
Address
100 Park St,Glens Falls,New York 12801
I Death Certificate Filed District Number Register Number
y£ City, Town or Village Glens Falls 5601 407
-
El Burial Date Cemetery or Crematory
08/27/2018 Pine View Crematorium
❑Entombment Address
I®Cremation Queensbury Town, New York
Date Place Removed
O ❑Removal and/or Held
and/or Address
Hold
01 Date Point of
0' LiTransportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
A Permit Issued to Registration Number
, Name of Funeral Home Carleton Funeral Home Inc 00281
Address
68 Main Stpo Box 67,Hudson Falls,New York 12839 _
Name of Funeral Firm Making Disposition or to Whom
I Remains are Shipped, If Other than Above
Address
tX
C. Permission is hereby granted to dispose of the human remains described above as indicated.
4. Date Issued 08/27/2018 Registrar of Vital Statistics Robert Curtis(ECactronicatySigned)
(signature)
Vi
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LU Date of Disposition SI Igo; Place of Disposition �h,1L_ r,,,��
(address)
t11'
CO
tt (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises (((( & iltts S Ptit
Z (please print)
1U Signature j? 4 Title (tzf 44r17,
(over)
DOH-1555 (02/2004)