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Hogan, Carl NEW YORK STATE DEPARTMENT OF HEALTH it -zip ` Burial - Transit Permit Vital Records Section Name First Middle Last Sex Carl Leroy Hogan Male Date of Death Age If Veteran of U.S. Armed Forces, June 28, 2011 83 War or Dates 1 9 5 - y-1- Place of Death Hospital, Institution or ,r City, Town or Village Argyle Street Address PLEASANT VALLEY NURSING FAC. Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending Circumstances Investigation Medical Certifier Name Title Dr. Edit Masaba, M - D - �' Address 113 4 S-4 . P--*- act Cn mac—•--" LA.. 'L ta3U. Death Certificate Filed District Number 9 Register Numb City, Town or Village ,-❑Burial Date Cemetery or Crematory June 30, 2011 Pine View Crematorium ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed ❑ Removal and/or Held . and/or Address Hold GERALD B.H. SOLOMON NAT. Date Point of CEM. ❑Transportation Shipment :, by Common Destination Carrier �u ❑ Disinterment Date Cemetery Address ❑ Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home, Inc. 00276 ., -, Address Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839 tF Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Y' Address - y -, Permission i hereby granted to dispose of the human rem described bo dicated. Date Issued Registrar Re istrar of Vital Statistics -es: (signature) District Number 39 7 ( n J Place OLC>/? G I i.�° R certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition L -30�•t( Place of Disposition P)o.0 z�,, cy,,, ,-Ake(ice g (address) , . (section) (lot number 4 ) (grave number) Name of Sexton or Per on in Charg of Premises 711,)V�ar thottt' (please print) i ASignature Title CRrzAvRi a(�- (over) DOH-1555 (02/2004)