Spaulding, Forrest NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last TSex
FORREST J. SPAULDING MALE
Date of Death Age If Veteran of U.S. Armed Forces,
07/19/1997 80 yeard War or Dates 1942-1947
Place of Death Hospital, Institution or
City, Town or Village NISKAYUNA Street Address 3421 STATE STREET
Manner of Death nNatural Cause ❑Accident Homicide Suicide ElUndetermined El Pending
Circumstances Investigation
Medical Certifier Name Title
ROBERTA MILLER M. D.
Address
113 HOLLAND AVENUE ALBANY NY 12208
Death Certificate Filed District Number Register Number
City, Town or Village NISKAYUNA 4652
Date y Cemetery or Crematory
El Burial 07/23/1997 PINE VIEW CREMATORY
Address
®Cremation AUEENSBURY, NY
Date Place Removed
ZRemoval and/or Held
•. and/or Address
Hold
Q Date Point of
Q Transportation Shipment
G 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. 00310
Address
68 MAIN ST. , HUDSON FALLS, NY 12839
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Z.
Permission is hereby granted to dispose of the human remains described above indicated.
� r
s Date Issued 07/21/1997 Registrar of Vital Statistics W'd
(signature)
District Number 4652 Place NISKAYUNA
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition Place of Disposition �%fu(:' �j 1 �/Y ( !� �✓ �
W. / (address)
mi
W
(section) (lot numqer) (grave number)
GName of Sexton or Person n Char of remises 1 c..jv Z-a
(please print) _
Signature 1 Title (� f' �yY) z- o
DOH-1555 (10/89) p. 1 of 2 VS-61