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Belden, Cameron NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex CAMERON JOSEPH EUGENE BEIDFN MALE Date of Death Age If Veteran of U.S. Armed Forces, 3/4/2017 26 War or Dates NO F- Place of Death Hospital, Institution or W City, Town or Village CITY OF BUFFALO Street Address ERIE COUNTY MEDICAL CENTER p Manner of Death❑Natural Cause ❑Accident ❑Homicide ❑Suicide ❑ Undetermined E Pending W Circumstances Investigation 0 Medical Certifier Name Title CI KATHERINE F. MALONEY, MD Address 501 KENSINGTON AVE. BUFFALO, NY 14214 Death Certificate Filed District Number Register Number City, Town or Village CITY OF BUFFALO 1401 9 ❑Burial Date Cemetery or Crematory 3/14/2017 PINE VIEW CREMATORY ['Entombment 1 Address x❑Cremation QUEENSBURY, NY _ Date Place Removed Removal and/or Held and/or Address F Hold Cl) - 0 Date Point of Cl. • ❑Transportation Shipment 0 by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home WILCOX & REGAN 01821 Address 11 ALGONKIN STREET TICONDEROGA, NY 12883 Name of Funeral Firm Making Disposition or to Whom IrTi Remains are Shipped, If Other than Above M Address CC II a' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 3/8/2017 Registrar of Vital Statistics ,----ktieti, '1 ( /) District Number 1401 Place BUFFALO, NY I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z La Date of Disposition 3 1/j/7 Place of Disposition j�173C jj 76,0 L ,7647 "'c ''y 2 / (address) W til (C (section) (1 tt number) (grave number) pName of Sexton o Pers in Charge of Premises - v, 4 4 6%-Yz ``�4.e z (please print) W Signature /�i` Title Gr'hil7L©,/ (over) DOH-1555 (02/2004)