Carpenter, John NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
John -W. Carpenter Male
Date of Death Age If Veteran of U.S.Armed Forces,
August 2, 1995 69 War or Dates No
' Place of Death Hospital, Institution or
City, Town or Village Street Address 40 Sheridan Lane
Y 9 ueensbur N
Manner of Death nx Natural Cause n Accident Homicide n Suicide Undetermined El Pending
_ Circumstances Investigation
f. Medical Certifier Name Title
Andrew Garner M.D.
Address
100 Broad Street Glens Falls, New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Queens bury, N.Y. 5657
Date Cemetery or Crematory
August 9, 1995 Pine View Crematory
El Burial
Address
x Cremation••••• Quaker Road Queensbury, New Yard
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
Date Point of
Rj F]Transportation Shipment
p by Common Destination
Carrier
[�Disinterment Date Cemetery Address
: ' Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
>' Name of Funeral Homes ing Teton-Hea ly F
Address
407 Bay Road Queensbury, New York 12804 T.
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human re s descrlb 'bove as indicated.
Date Issued Aug. 9, 1995 Registrar of Vital Statistics
(signature)
District Number 5657 Place
f certify that the remains of the decedent identified above were disposed of In accordance with this permit on:
Date of Disposition Place of Disposition /J1(.� � �/►��������
(address)
in
(section)/ /� ton be (grave number)
Name of Sextor or Perso in Charge of Pr ises .�.�1�1/t o f4
j
51 (please print)
Signature Title
DOH-1555 (10189) p. 11 of 2 VS-61