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Mingo Jr., Andrew NEW YORK STATE DEPARTMENT OF HEALTH F H © 33 Vital Records Section m Burial - Transit Permit • Name First Middle Last Sex Andrew Paul ingo, Jr. Male Date of Death Age if,� ,eteran of U.S. Armed Forces, November 3, 2017 41War or Dates Place of Death Hospital, Institution or WCity, Town or Village Glens Falls Street Address Glens Falls Hospital W_111 Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined Pending Circumstances Investigation W Medical Certifier Name Title Michael Sikirica MD, Address 50 Broad Street Waterford, NY 12188 Death Certificate Filed District Number 5.�, Register Numl ber City, Town or Village 1 �Lo`-P _.''❑Burial Date Cemetery or Crematory October 30, 2017 Pine View Crematorium ❑Entombment Address x, MCremation Quaker Road Queensbury,NY 12804 s Date Place Removed z Removal ❑ and/or and/or Held p Hold Address Date Point of a. ❑Transportation Shipment t)): by Common Destination 3 Carrier _ ElDisinterment Date Cemetery Address ❑ Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home, Inc. 00281 z.- 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 w 0.. Permission is ere y granted to dispose of the human re ains described above s indicate Date Issued �i nt„ �Q l Registrar of Vital Statistics .ar--e__(� / .H- " (sig ature) _.pl...n District Number .. -isol Place ,L A FT.( I certify that the remains of the decedent identified above were disposed of in accordance wit this permit on: Ew Date of Disposition 10/30/2017 Place of Disposition Quaker Road Queensbury,NY 12804 (address) `. OA LE (section) Apt number) (grave number) 9 aName of Sexton or Person in Charge of P emises t A t "itb (plea e print) U Signature Title (KEI>►I}t,t, (over) DOH-1555 (02/2004) .