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O'Hare, Frederick ti? , NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Frederick O'Hare Male Date of Death Age If Veteran of U.S. Armed Forces, November 26, 2016 91 War or Dates Place of Death Hospital, Institution or W" City, Town or Village Hudson Falls Street Address 7 Willow Street, Hudson Falls, NY 12839 W' Manner of Death Jj Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending Circumstances Investigation W, Medical Certifier Name Title a Address Death Certificate Filed District Number Register Number City, Town or Village `! ❑Burial Date Cemetery or Crematory December 2, 2016 Pine View Crematorium ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z ❑ Removal and/or Held and/or Address F Hold Pine View Crematorium Date Point of ❑Transportation Shipment Q) by Common Destination O Carrier ❑ Disinterment 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 H Remains are Shipped, If Other than Above Address CC Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued ///a.y // Registrar of Vital Statistics a � (signature) District Number - Place �/;(/� o iClc. ci,S c yr / //5 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W'' Date of Disposition 12/02/2016 Place of Disposition Quaker Road Queensbury,NY 12804 (address) W' (section) , (lot number) (grave number) a / Name of Sexton or Person in Charge of Premises 6 id+ r SA ft' (p,ase print) W Signature et Title i.En11111d2, (over) DOH-1555 (02/2004)