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Vanderzyden, Bruce tr NEW YORK STATE DEPARTMENT( F HEALTH I zzc Vital Records Section Burial - Transit Permit Name First Middle Last Sex Bruce Vanderzyden Male Date of Death Age If Veteran of U.S. Armed Forces, April 30, 2011 74 War or Dates Place of Death Hospital, Institution or City, Town or Village Queensbury Street Address 10 Little Street Manner of Death J Natural Cause D Accident 0 Homicide 0 Suicide Undetermined ri Pending Circumstances Investigation Medical Certifier Name Title Gerald F Abess MD, Address 3 Irongate Ctr. Glens Falls, NY 12801 Death Certificate Filed District Number .gtister Number City, Town or Village () ) ❑Burial Date Cemetery or Crematory May 3, 2011 Pine View Crematorium ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Removal Date Place Removed and/or and/or Held Hold Address Date Point of Transportation Shipment by Common Destination Carrier Disinterment Date Cemetery Address rs 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 Name of Funeral Firm MakingDisposition or to Whom P Remains are Shipped, If Other than Above Address Permission is hereby granted to dispose of the human re ain described a o e as indicated. `` Registrar of Vital Statistics Date Issued�l a.--I�Q l) _ �C.�_ G - (signature) District Number -Lac Numberc-Lac ) Place =�z i certify that the remains of the decedent identified above were disposed of in accordan a ith this permit on: Date of Disposition C'+(-I I Place of Disposition T Ine�R«+ l <rn.e 'd fl,,,� (address) (section) (lot numb ) (grave number) Name of Sexton or Per n in Charg f Premises C rts4o L an„t }' / � P (please print) Signature L ��((( ,�, ///��_ Title C�(Z f~rh OL (over) DOH-1555 (02/2004)