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Northrup, Gary NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Gary Reynolds Northrup Male 4 Date of Death Age If Veteran of U.S. Armed Forces, , December 25, 2018 80 War or Dates , Place of Death Hospital, Institution or City, Town or Village Kingsbury Street Address 51 Dean Road Manner of Death Natural Cause ID Accident El Homicide I=1 Suicide El Undetermined Pending 0 Circumstances Investigation W Medical Certifier Name Title Mary Stine, NP Address West Mountain Health Care Facility Queensbury, NY 12804 5. Death Certificate Filed District Number Register Number City, Town or Village (p D. 1 I t' 0 Burial Date Cemetery or Crematory r . December 27, 2018 Pine View Crematorium El Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Al. Date Place Removed . ❑ Removal and/or Held 4 and/or Address ,E. Hold : Date Point of 0 Transportation Shipment by Common Destination L. Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address 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 Remains are Shipped, If Other than Above Address Permission is hereby granted to dispose of the human remai escribed above as indicated. Date Issued / FA.8' c/Z Registrar of Vital Statistics ��.., - L (signature) i District Number 5-7 toa Place i c,:.,.,` y? ,,. ,--. I certify that the remains of the decedent identifiedebove were disposed of in accordance with this permit on: Date of Disposition 12/27/2018 Place of Disposition Quaker Road Queensbury,NY 12804 p„,�. /4►4L.0 Fr►,�,twr y (address) r (section) �\\ (lot number) (grave number) U Name of Sexton or Person in Charge of Premises arri-ty vats I (please print) ', Signature ,prt LJ Title Cre"C.410 f (over) DOH-1555 (02/2004)