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Weller, Zackery Allen f75- NEWYORK STATE DEPARTMENT OFHEALTH Bu rial of Vital Records - Transit Permit Name First Middle Last Sex Zackery Allen Weller Male Date of Death Age If Veteran of U.S.Armed Forces, 02/13/2024 25 Years War or Dates i... Place of Death Hospital,Institution or WCity,Town or Village Fort Edward Town Street Address 557 Lower Elizabeth Street,Fort Edward Town,New York 12839 p Manner of Death 0 Natural Cause Accident 0 Homicide Suicide Undetermined Pending WW I—ICircumstances Investigation Medical Certifier Name Title 4 Vicky Campbell Coroner Address 1517 COUNTY RTE 31,Granville, New York 12832 Death Certificate Filed Town Of Fort Edward District Number Register Number City,Town or Village 5755 16 Burial Date Cemetery,Crematory or Facility Name 02/16/2024 Pine View Crematorium Entombment _ Address ©Cremation Queensbury Town,New York Donation 6 0 Removal Date Place Removed — and/or and/or Held N Hold Address 0 a Date Point of (/)ETransportation p by Common Shipment 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 H Remains are Shipped,If Other than Above 2 Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/16/2024 Registrar of Vital Statistics Aimee G Mahoney(&ectronicallySigned) (signature) District Number 5755 Place Town Of Fort Edward I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I— Z Date of Disposition .2—/V'20 fV Place of Disposition ?r n)(' LIJ Us E,-e. Cie ma � (address) W CO Lr (section) (lotnum er) (grave number) 0 -�Name of Sexton or Person in Charge of Premis s yw/0" i) 1„ Z (please print) ILI � / '� Title - Signature c� DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 7 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg. or License#