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Ash, Ronald NEW YORK STATE DEPARTMENT OF HEALTH r it '+ ' Vital Records Section Burial - Transit Pe mit Name First Middle Last Sex Ronald Edward Ash Male Date of Death Age If Veteran of U.S. Armed Forces, May 20, 2017 69 War or Dates Plac ✓path Hospital, Institution or City no r Village M o c r c.=/' Street Address 16 Fawn Road Manner of Death X❑Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending Circumstances Investigation i Medical Certifier Name Title CI Michael Sikirica MD, Address 50 Broad Street Waterford, NY 12188 Death ificate Filed District Number Register Number Ci 'Town r Village � 0y( �s((pp a ❑Buna Date Cemetery or Crematory May 26, 2017 Pine View Crematorium ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed ❑ Removal and/or Held and/or Address Hold 0. Date Point of ❑Transportation Shipment ( by Common Destination q Carrier ❑ Disinterment Date - ' Cemetery Address il ElReinterment Date Cemetery Address ' Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home, Inc. 00281 Address t Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839 ' ,, Name of Funeral Firm Making Disposition or to Whom -11 Remains are Shipped, If Other than Above Address :5 0,., Permission is hereby ranted to dispose of the human remainslescribed a o e indicated. 4,: Date Issued / Registrar of Vital Statistics jajak.� signature District Number 1/57PD Place 35/ r /c /204 7 ":0ay( /V y ioy,00 j I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: —' Date of Disposition 05/26/2017 Place of Disposition Quaker Road Queensbury,NY 12804 (address) w VI (section) „/(lot number) (, (grave number) Name of Sexton or Person in Charge of Premises lti',$I J gA4/1+ _Z (plea�e pant) , ' Signature d i ATitle faElOript (over) DOH-1555 (02/2004)