Stone, Roy Edward Sr. 11
NEW YORK STATE DEPARTMENT OF HEALTH �� I
Bureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
Roy Edward Stone Sr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/13/2022 48 Years War or Dates
1.,. Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
pManner of Death ❑X Natural Cause ❑Accident El Homicide OSuicide Undetermined riPending
C3 I—ICircumstances Investigation
G Medical Certifier Name Title
Gamal Khalifa MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 629
Burial9
Date Cemetery,Crematory or Facility Name
12/15/2022 Pine View Crematorium
Entombment Address
Cremation Queensbury Town,New York
Donation
Z
['Removal Date Place Removed
and/or and/or Held
I-
- Hold Address
t
0
a. Date Point of
t/N Transportation
p by Common Shipment
Carrier Destination
EDisinterment Date Cemetery Address
riReinterment 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
i.. Remains are Shipped,If Other than Above
I Address
CC
W
n• Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/15/2022 Registrar of Vital Statistics 9Kegan.No(in(E(ectronicaltySigned)
(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:
Z //
W Date of Disposition —i7 Z�z L Place of Disposition �,maP rJ Cr� .t t P�(
2 (addree)
W
Q (section) . (lot number) (grave number)
GName of Sexton or Person in Charg of Pre is �►��f�Orri L JL12�
Z (please print)
W Signature Title (7(�¢-AT'I-
DOH-1555(07/18)p 1 of 2 J
0J 16501
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#