Haynes, Edmund ii
NEW YORK STATE DEPARTMENT OF HEALTH t . 1 o
Vital Records Section Burial - Transit Per it
7is-:, Name First Middle Last Sex
Edmund Thomas Haynes Male
Date of Death Age If Veteran of U.S. Armed Forces,
10/30/2018 75 Years War or Dates
Z Place of Death Hospital, Institution or
It City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death J Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ri❑Pending
Circumstances Investigation
w Medical Certifier Name Title
0 Farhana Kemal MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 513
f El Burial Date Cemetery or Crematory
11/02/2018 Pine View Crematorium
�` ❑Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
El Removal and/or Held
Y.Y- and/or Address
r Hold
o Date Point of
0' ❑Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
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
t' Remains are Shipped, If Other than Above
2 Address
it
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
_' Date Issued 11/02/2018 Registrar of Vital Statistics Robert A Curtis fEactronicaarySigned)
(signature)
`<' District Number 5601 Place Glens Falls, New York
i- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
Ili Date of Disposition iii'71I$ Place of Disposition ;,,L o-
a'' (addr s)
CC (section) , (lot numb r) (grave number)
8 Name of Sexton or Person in Charge of Premises fib, '3„.
please print)
W Signature L..r Title Alt AO&
(over)
DOH-1555 (02/2004)