Deyette, Steven Wayne Sr. It SZ
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Steven Wayne Deyette Sr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/10/2023 67 Years War or Dates 1973-1975
1_, Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
W netermneenn
W Manner of Death Ud id P
El Natural Cause ❑Accident ElHomicide Suicide dig
Circumstances Investigation
W Medical Certifier Name Title
O Scott Biasetti 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 22
ElBurial Date Cemetery,Crematory or Facility Name
01/13/2023 Pine View Crematorium
Entombment Address
ElCremation Queensbury Town,New York
DDonation
ZO❑Removal Date Place Removed
and/or and/or Held
F Hold Address
CO
0
Q. Date Point of
Cl)❑Transportation
Q by Common Shipment
Carrier Destination
Date Cemetery Address
Disinterment
EI
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
H Remains are Shipped,If Other than Above
2 Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/12/2023 Registrar of Vital Statistics Megan Nolin(ECectronicaCCySigned)
(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: /
Date of Disposition //4-/-Zo0 3 Place of Disposition } , N e v;e,, - £.e 4,4
-fa P-�t
2 (address) l
W
LC (section) - (lot numb ) I
(grave number)
8 Name of Sexton or Person in Charg f Premises I<ia)10/1'/ t aC'
Z (please print)
W Signature Title 0e4.,-,' ._V---
DOH-1555(07/18)p 1 of 2
. 1
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
1 Official Funeral Directors Reg.or License#