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Needham, Daniel NEW YORK STATE DEPARTMENT OF HEALTH 75" Vital Records Section Burial - Transit Permit Name First Middle Last Sex `= Daniel Needham Male Date of Death Age If Veteran of U.S. Armed Forces, January 2, 2016 49 War or Dates Place of Death Hospital, Institution or ut City, Town or Village Argyle Street Address 639 West Valley Road Manner of Death ❑Natural Cause ❑ Accident ❑ Homicide 0 Suicide ❑ ❑Undetermined Pending Circumstances Investigation 11 Medical Certifier Name Title Michael Sikirica MD, Address 50 Broad Street Waterford, NY 12188 Death Certificate Filed District Number Register Number City, Town or Village S15?) i;r0 Date Cemetery or Crematory (/ , a o / & Pine View Crematorium ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z ❑ Removal and/or Held { and/or Address E Hold Date Point of 0 °❑Transportation Shipment (A by Common Destination Q Carrier ElDisinterment 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 Is- Remains are Shipped, If Other than Above Address W Permission is hereby granted to dispose of the human re ains described Bove n•icated. Date Issued i.-s-?GJL, Registrar of Vital Statistics re (signature) District Number 5J'75?J Place ok)n I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition W p I//q//L Place of Disposition Quaker Road Queensbury,NY 12804 (address) W (section) � (lot number) (grave number) /� arg Name of Sexton or Person in Ch f Premises (6b1 St dr-A- Z 7 (//L—ease print) W. Signature �� Title aikAttl 2 (over) DOH-1555 (02/2004)