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Boucher, Arthur Henry F , ll°) NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Arthur Henry Boucher Male Date of Death Age If Veteran of U.S.Armed Forces, 11/10/2020 79 Years War or Dates 1958-1959 Place of Death Hospital,Institution or WCity,Town or Village Moreau Town Street Address 248 Ferry Boulevard,Moreau Town,New York 12803 pManner of Death ©Natural Cause ❑Accident 0 Homicide Suicide El Undetermined ❑Pending C.) Circumstances Investigation W Medical Certifier Name Title CI Michael Adams MD Address 1299 Route 9,Gansevoort Hamlet,New York 12828 Death Certificate Filed District Number Register Number City,Town or Village Moreau 4562 49 ❑Burial Date Cemetery,Crematory or Facility Name 11/12/2020 Pine View Crematorium ElEntombment Address 0 Cremation Queensbury Town,New York Donation z Removal Date Place Removed and/or and/or Held N Hold Address O O. Date Point of Cl) Li Transportation Q by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above Address W 0- Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/12/2020 Registrar of Vital Statistics Leeann 9Mtc cabe(ECectronicalry Signed) (signature) District Number 4562 Place Moreau, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: WDate of Disposition 11/'/-Z,ZO Place of Disposition a „i.e ) (,"tern 2 (address) W NCC (section) (lot nu er) (grave number) g Name of Sexton or Person in Charge of remises �f?r 1O.4`' E- (please print/ liJ i nature d Title Dre I- S g 1C li DOH-1555(07/18)p 1 of 2 .f• t �� Public Health Law Sec. 4145(2b) O 14 I . Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# 1