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Underwood, Ernest Hubert NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Ernest Hubert Underwood Male Date of Death Age If Veteran of U.S.Armed Forces, 10/04/2021 88 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Fort Edward Town Street Address 232 Perkins Drive Extension,Fort Edward Town,New York 12839 111 Manner of Death ©Natural Cause ❑Accident Homicide Suicide ❑Undetermined ❑Pending ✓ Circumstances Investigation W Medical Certifier Name Title Jean Hanson PA Address 325 Main Street,Hudson Falls Village,New York 12839 Death Certificate Filed District Number Register Number City,Town or Village Fort Edward 5755 59 ❑Burial Date Cemetery,Crematory or Facility Name 10/08/2021 Pine View Crematorium ❑Entombment Address O Cremation Queensbury Town,New York ElDonation Removal Date Place Removed and/or and/or Held N Hold Address O G. Date Point of to 1-1 Transportation 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 1— Remains are Shipped,If Other than Above 2 Address CC W 0. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/07/2021 Registrar of Vital Statistics Aimee L Mahoney(ECectronicalty Signed) (signature) District Number 5755 Place Fort Edward, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: f" (� Z Date of Disposition ,�—A'ZU iA/ Place of Disposition i J �,�,J ,,^ �-4p it! (address/ W CC N (section) (lot Imbed (grave number) 8 Name of Sexton or Person in Cha of Premises 14T ®�'r l � Z r (please print/ W Signature /f/ /s/ Title Oec..- � l DOH-1555(o7/18)p t of 2 - e ( L31Li Public Health Law Sec. 4145(2b) Receipt Human remains of ''' r ''^ elivered on •FJ 20 Pine View Cemetery Representing the funeral home named on 13ugial permit Official Funeral Directors Reg.or License#