Breckheimer, Edward Otto -y t # ,16
NEW YORK STATE DEPARTMENT OF H EALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Edward Otto Breckheimer Male
Date of Death Age If Veteran of U.S.Armed Forces,
10/28/2021 73 Years War or Dates 1969-1971
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
'p Manner of Death Natural Cause El Accident El Homicide Suicide ❑Undetermined ❑Pending
C.) Circumstances Investigation
Q Medical Certifier Name Title
Abigail Macomber PA
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 472
❑Burial Date Cemetery,Crematory or Facility Name
11/01/2021 I Pine View Crematorium
Entombment Address
0 Cremation Queensbury Town,New York
EiDonation
Removal Date Place Removed
and/or and/or Held
N Hold Address
0
0- Date Point of
Cl) ❑Transportation
p 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
F•• Remains are Shipped,If Other than Above
2 Address
CC
W
CL
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/01/2021 Registrar of Vital Statistics Robert Andrew Curtis(ECectronicalTySigned)
(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 I—
Date of Disposition I Z i_u Place of Disposition M V„ 4,0 ti
(address)
W
to
CC (section) (lot number/ (grave number)
aName of Sexton or Person in Charge f Premises L l�syp� S .tt
(pleas print)
Signature J .� Title t/�r^"104.-
DOH-1555(07/18)p 1 of 2
�.,.� ..°.
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named,on burial permit
Official Funeral Directors Reg.or License#