Hall, Sr. Henry if
NEW YORK STATE DEPARTMENT OF HEALTH .y $7t0
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Henry B. Hall Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 26, 2018 85 War or Dates Korea
Place of Death Hospital, Institution or
City, Town or Village Hudson Falls Street Address 18 Union Street
Manner of Death Natural Cause � Accident Homicide Suicide El Undetermined Pending
W Circumstances Investigation
W' Medical Certifier Name Title
oe
Address
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Death Certificate Filed District Number Register Number
City, own or Village 5'7d ( tea,
❑Burial Date Cemetery or Crematory
Pine Vew Crematorium
'IV:,,❑Entombment
Address
®Cremation Queensbury,NY 12804
Date Place Removed
• Removal and/or Held
0: and/or Address
Hold
(11 Date Point of
0. ❑Transportation Shipment
0 by Common Destination
C) Carrier
ElDisinterment Date Cemetery Address
Reinterment 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
} Remains are Shipped, If Other than Above
• Address
W
' Permission is hereby granted to dispose of the human remains descri ed above as indicated.
Date Issued /0.,90/3' Registrar of Vital Statistics :. 10
' (signature)
District Number 5 7,2 C, Place-\1_1(10_0.,e_ ,)1„1s, G
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ill Date of Disposition /D/30/Jf Place of Disposition Queensbury,NY 12804
(address)
CtO
`; (section) (lot r tuber) (grave number)
0` Name of Sexton or Person in Charge of Premises
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(please pnnt)
41, Signature Title Al+EMATO L
(over)
DOH-1555 (02/2004)