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Mattison, Evertt Raymond 111 • -)y NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Everett Raymond Mattison III Male Date of Death Age If Veteran of U.S.Armed Forces, 04/21/2023 36 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Fort Ann Town Street Address State Route 149 Road, Fort Ann Town, New York 12827 11.1 p Manner of Death EINatural Cause []Accident []Homicide Suicide nUndetermined ❑Pending W Circumstances Investigation U W Medical Certifier Name Title John Aiken Coroner Address 40 Burquist Road, Fort Ann Town,New York 12827 Death Certificate Filed Town Of Fort Ann District Number Register Number City,Town or Village 5754 8 []Burial Date Cemetery,Crematory or Facility Name 04/25/2023 Pine View Crematorium []Entombment Address ©Cremation Queensbury Town,New York Donation 0❑Removal Date Place Removed and/or and/or Held Hold Address U) 0 d Date Point of (f)DTransportation by Common Shipment Carrier Destination Date Cemetery Address Disinterment Date Cemetery Address 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 i_ Remains are Shipped,If Other than Above Address CC W n Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 04/24/2023 Registrar of Vital Statistics Miranda Jferringsliam(Electronically Signed) (signature) District Number 5754 Place Town Of Fort Ann I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: / 2. Z Date of Disposition y 4173 Place of Disposition 2 (address) W U)CC (section) /1 (lot number) (grave number) 0 Name of Sexton or Person in Charge of Premises " �— H /lease print) Z �j� W Signature �� Title �PY1nW DOH-1555(07/18)p t of 2 y y b S 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#