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Carlin, James NEW YORK STATE DEPARTMENT OF HEALTti --)s Z Vital Records Section Burial - Transit Permit Name First Middle Last Sex James D.Carlin ;{ Male Date of Death Age if Veteran of U.S. Armed Forces, 0- 1 = 09/14/2018 55 Years War or Dates I- Place of Death Hospital, Institution or City, Town or Village Johnsburg Town Street Address Elderwood at North Creek :000, Manner of Death©Natural Cause ❑Accident ❑Homicide ❑Suicide ❑ Undetermined ❑Pending Circumstances Investigation rril Medical Certifier Name Title James Hindson MD 11, Address 112 Ski Bowl Rd,Johnsburg Town, New York 12853 :74 Death Certificate Filed District Number Register Number 00, City, Town or Village North Creek 5655 23 ❑Burial Date Cemetery or Crematory 09/17/2018 Pine View Crematory El Entombment Address ®Cremation Queensbury Town, New York Date Place Removed ❑Removal and/or Held i.00and/or Address Hold Date Point of ❑Transportation Shipment C by Common Destination Carrier rs ❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address 41 Permit Issued to Registration Number Name of Funeral Home Miller Funeral Home 01199 Address 6357 Nys Rte#30, Indian Lake,New York 12842 Name of Funeral Firm Making Disposition or to Whom • Remains are Shipped, If Other than Above r Address Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 09/17/2018 Registrar of Vital Statistics KothkenC.Lorak(ECectronica1TySigned) (signature) District Number 5655 Place North Creek, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition Qin II i, Place of Disposition k?Ai..._ 4 ,tdr� _,' (address) 17 (section) d (lot number) (grave number) Name of Sexton or Person in C arge of Pre ises `Zr, k,ff owl ( ease print) tV, GVi �V Signature � Title ,r /1141111A- (over) DOH-1555 (02/2004)