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Eddy, Gardner Lyle i NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Gardner Lyle Eddy Male Date of Death Age If Veteran of U.S.Armed Forces, 12/15/2019 54 Years War or Dates E Place of Death Hospital,Institution or W City,Town or Village Hudson Falls Village Street Address 9 Ferris Street, Hudson Falls Village, New York 12839 p Mannerof Death Natural Cause Accident Homicide Suicide ❑Undetermined ©Pending W Circumstances Investigation V Title W Medical Certifier Name Robert Lemieux Coroner Address 415 Lower Main Street,Hudson Falls Village,New York 12839 Death Certificate Filed District Number Register Number City,Town or Village Hudson Falls Village 5726 22 Burial Date Cemetery,Crematory or Facility Name 12/20/2019 Pine View Crematorium ❑Entombment Address Cremation Queensbury Town,New York 11 Donation z ❑Removal Date Place Removed and/or and/or Held �-' Hold Address N O d' Date Point of N ❑Transportation Shi ment p by Common P Carrier Destination Disinterment Date Cemetery Address 0 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 orto Whom Remains are Shipped,If Other than Above Address cc W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/17/2019 Registrar of Vital Statistics Cynthia Bardin(ECectronicaCCy Signed (signature) District Number 5726 Place Hudson Falls Village, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: H Z Date of Disposition Place of Disposition ,) mi I1J (address) W Cl) (section) (/at number) (grave number) cc O Name of Sexton or Person in Charge of Premises "'°'"� c' °� (please print) Z f G W Signature Title DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 013170 Receipt Human remains of delivered on - , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# f