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Carleton, Warren 17 17If NEW YORKSTATE DEPARTMENT OF HEALTH - Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Warren Carleton Male Date of Death Age If Veteran of U.S.Armed Forces, 12/01/2020 61 Years War or Dates H Place of Death Hospital,Institution or WCity,Town or Village Glens Falls Street Address Glens Falls Hospital 0 Manner of Death ©Natural Cause ❑Accident ❑Homicide El Suicide Undetermined Pending W V Circumstances Investigation W Medical Certifier Name Title 0 Scott Miller PA Address 100 Park St,Glens Falls, New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 556 — ❑Burial Date Cemetery,Crematory or Facility Name 12/08/2020 Pine View Crematory El Entombment Address O Cremation Queensbury Town, New York ▪Donation Z 0 Removal Date Place Removed and/or and/or Held H Hold Address N 0 a. Date Point of co ❑Transportation p by Common Shipment Carrier Destination Date Cemetery Address ❑Disinterment ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Brewer Funeral Home Inc 00211 Address 24 Church Street PO Box 500,Lake Luzerne,New York 12846 Name of Funeral Firm Making Disposition or to Whom H Remains are Shipped,If Other than Above 2 Address CC W CI- Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/08/2020 Registrar of Vital Statistics Robert Andrew Curtis(Electronically Signed) (signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition J'L /0/W Place of Disposition W Z IL. 4---- (address) W CC CC Title 4(lot number) (grave number) 0• Name of Sexton or Person in Charge of Pr ises rw 1. �q^.+t�./ Z (pleas print) W Signature LN Title (04t147k DOH-1555 07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 0 1 4 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#