Combs, Ronald NEW YORK STATE DEPARTMENT OF HEALTH
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Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Ronald Preston Combs Male
z Date of Death Age If Veteran of U.S. Armed Forces,
June 14, 2017 65 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Granville Street Address 225 Guilder Hollow Road
WI::of Deathyr_ i Natural Cause I:: Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
0' Ageel Gillanni,
Address
102 Park Street Glens Falls, NY 12801
Deat - ificate Filed District Number Register Number
City, or Village G.124Nu ILi 5'7S'6 a 1
❑Burial Date Cemetery or Crematory
June 16, 2017 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
r Hold
rh Date Point of
a ❑Transportation Shipment
0) by Common Destination
0 Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
El Reinterment
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
Imo;: Remains are Shipped, If Other than Above
Address
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Ui
[L.: Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06 I Is lao 11 Registrar of Vital Statistics eftivaex IN\QivaQ-Qb
(signature)
District Number siS6 Place'tbWN OF O V 1U.,.E
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 06/16/2017 Place of Disposition Quaker Road Queensbury,NY 12804
2 (address)
Ill
CO
W (section) (lot number) (grave number)
Z Name of Sexton or Person in Charge of remises (1•�sfpits sent
( lease print)
W Signature . Title
(over)
DOH-1555 (02/2004)