Whitt, Timothy Michael 6 1.--- It S-
NEW YORK STATE DEPARTMENT OF HEALTH ``.._y__ i Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Timothy Michael Whitt Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/28/2022 59 Years War or Dates
F- Place of Death Hospital,Institution or
Z City,Town or Village Kingsbury Town Street Address 116 Farley Road,Kingsbury Town,New York 12839
ILI
p Manner of Death Natural Cause Accident Homicide Suicide Undetermined ❑Pending
Circumstances Investigation
W Medical Certifier Name Title
0 John Aiken Coroner
Address
40 Burquist Road,Fort Ann Town,New York 12827
Death Certificate Filed Town Of Kingsbury District Number Register Number
City,Town or Village 5762 28
HBurial Date Cemetery,Crematory or Facility Name
12/30/2022 Pine View Crematorium
Entombment Address
Cremation Queensbury Town,New York
Donation
0 Removal Date Place Removed
and/or and/or Held
F- Hold Address
N
0
O. Date Point of
CO Transportation Shipment
Q by Common
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
I— Remains are Shipped,If Other than Above
i Address
CC
Ili
0. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/29/2022 Registrar of Vital Statistics Cynthia Bardin(Ehctronicalty Signed)
(signature)
District Number 5762 Place Town Of Kingsbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: //�
Z Date of Disposition /(-pptjPlace of Disposition -'(L ,
W — (address)
W
CC (section) /� (lot number) `r— (grave number)
C Name of Sexton or Person in Charge of P ' es ^ %'`�
Z (p/ a print)
W Signature Title [ "Li(t 4t
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 1
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#