Call, John Fredrick . 1q-----'', 4 ' Sr
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
John Fredrick Call Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/03/2022 81 Years War or Dates 1959-1962
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation
W Manner of Death n I I I I n n I I g
� I 'Natural Cause I 1Accident I 'Homicide Suicide Undetermined Pending
W Circumstances Investigation
C)
W Medical Certifier Name Title
CI Courtney Diamond NP
Address
170 Warren St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 605
Burial Date Cemetery,Crematory or Facility Name
r 12/06/2022 Pine View Crematorium
T Entombment Address
▪Cremation Queensbury Town,New York
▪Donation
ZZ Removal Date Place Removed
and/or and/or Held
H Hold Address
U)
0
CL Date Point of
Cl) Transportation Shipment
p by Common
Carrier Destination
Date Cemetery Address
Disinterment
Date Cemetery Address
I 1 Reinterment
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
S Address
Q
W
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/05/2022 Registrar of Vital Statistics began Notin(ECectronicatty 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:
Z Date of Disposition IZ 11 lZ Place of Disposition Ai A.,v.,_ Z.,td
ILI
2 (address)
W
N
CC (section) // (lot number) (grave number)
0Name of Sexton or Person in Charge of Premises l e` �' il
(ease print)
Z (WINO ye
W Signature Title
DOH-1555(07/18)p 1 of 2
N. • (?
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# -