Webster, John Orlia Jr. #9 O
NEW YORKSTATE DEPARTMENT OF HEALTH L1:-,) Burial - Transit Permit
Bureau of Vital Records �.
Name First Middle Last Sex
John Orlia Webster Jr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
11/02/2022 61 Years War or Dates
F— Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death Ii Natural Cause Accident Homicide ESuicide Undetermined El Pending
IJJ
0 Circumstances Investigation
aILI Medical Certifier Name Title
David Foote MD
Address
340A Main Street,Hudson Falls Village,New York 12839
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 556
ElBurial Date Cemetery,Crematory or Facility Name
11/04/2022 Pine View Crematorium
Entombment Address
IIICremation Queensbury Town,New York
Donation
6❑Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
a. 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
1— Remains are Shipped,If Other than Above
N Address
CC
W
a. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/03/2022 Registrar of Vital Statistics Megan NoCin(Electronica[Ty Signed)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
l-
Z Date of Disposition II I 4 ZZ Place of Disposition if L
W
2 (address)
W
CO (section) number) (grave number)
• Name of Sexton or Person in Cha a of Premises d.,(lot
� rt
z
/phase print/
W Signature Title riot,(N 2
DOH-1555(07/18)p 1 of 2
• 1 C4 q
Public Health Law Sec. 4145(2b)
Receipt
1
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#