Henry, William S NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
William Safford Henry Male
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Date of Death Agee If Veteran of U.S.Armed Forces,
October 21, 1992 83 War or Dates
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Z Place of Death Hospital, Institution or
W ity own or Village Glens Falls Street Address Eden Park Nursing Home
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W! Manner of Death ® Natural Cause Accident ❑Homicide ❑ Suicide Undetermined ❑ Pending
Circumstances Investigation
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Medical Certifier Name Title
0.
David Foote Md
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Address
Rt 4, Hudson Falls, H.Y. 12839
Death Certificate Filed District Number Register N ber
City, own or Village Glens Falls 5601
Date Cemetery or Crematory
❑Burial October 22, 1992 Pine Vier Crematorium
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remation Address
Tn of 9ueensbury, NY 12804
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Z Date Place Removed
0 ❑ Removal and/or Held
H' and/or Hold :... ........................................
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Address
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tL Date Point of
Ln [:]Transportation by: Shipment
pl Common Carrier . ...... .....
Destination
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Disinterment Date Cemetery Address
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Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm Carleton Funeral Home Inc. 00307
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Address
P.O. Box 67, 68 Main St. , Hudson Falls, N.Y. 12839
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Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
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....Address ..... ..... .....................
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Permission is ereb granted to dispose of the hum !remains dascrib above a indicated.
Date Issued y Registrar of Vital Statistics
(sig ature)
District Number �7v6� Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition ` v2 Place of Disposition / /JV L�/'�4� ��/liI /�/�l LIA-1
(address)
Uj
U) (section) (lot number) (grave number)
trara o Premises _ 9
p Name of Sexton or Person in Charge Pi
Z (please print)
w' Signature �, Title
DOH-1555 (10/89) p. 1 of 2 VS-61