Bristol, George NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Rev. George Fairbanks Bristol Male
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9
Date of Death Age If Veteran of U.S.Armed Forces,
March 3, 1993 100 War or Dates
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Z Place of Death Hospital, Institution or
it Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death.:: ..... _ ................. ..... ...::......:. -: .......... . Undetermined d. .:... Pendiri .... ... _::::::::.
Natural Cause ❑ Accident ❑Homicide ❑ Suicide 9
Circumstances Investigation
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Medical Certifier Name Title
ip Philip J. Gara Jr. MD
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Address
7240 Upper Broadway, Ft. Edward, MY 12828
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Death Certificate Filed District Number Register Number
it Town or Village Lj;j,< A,1 5 $(,U ( `'A
Date Cemetery or Crematory
❑Burial March 4, 1993 Pine View Crematorium
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__.
Cr&ation Address
Tn of 9ueensbury, NY 12804
Z Date Place Removed
2 ❑ Removal and/or Held
F- and/or Hold ` .. ......... ..
Address
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OL Date Point of.........
N []Transportation by Shipment
p' Common Carrier ........................
Destination
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❑ Disinterment
Date Cemetery Address
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❑ Reinterment
Address Date Cemetery
Permit Issued to Registration Number
Name of Funeral Firm Carleton Funeral Home Inc. 00307
Address _......
P.O. Box 67, 68 Main St. , Hudson Falls, N. Y. 12839
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N.: Name of Funeral Firm Making Disposition or to Whom
g Remains are Shipped, If Other than Above
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'> Address
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ii
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Permission is hereby granted to dispose of the human sins described above as indicated.
Date Issued Registrar of Vital Statistics A.•��Q ,/✓`t�.Q�h
(signature)
District Number no Place z af::9z/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
uDate of Disposition `/.3 Place of Disposition
2 (address)
ur'.
Cl) (section) (lot number) (grave number)
0 —
p' Name of Sexton Rr Person in Charge of Premises
Z' ) (please print)
W Signature Title
DOH-1555 (10/89) p. 1 of 2 VS-61