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Ouellette, Roland 1 / 11 NEW YORK STATE DEPARTMENT OF HEALTH .. it Vital Records Section Burial - Transit Permit Name First Middle Last Sex Roland Albert Ouellette Male Date of Death Age If Veteran of U.S. Armed Forces, December 30, 2016 79 War or Dates 1—, - of Death Hospital, Institution or Z`W- own or Village Glens Falls Street Address The Pines W, 'anner of Death Li Natural Cause ❑ Accident ❑ Homicide El Suicide D Undetermined ❑ Pending Circumstances Investigation W Medical Certifier Name Title 0 Melissa Decker, M.D. Dr. Address 100 Park Street Glens Falls, NY 12801 i - 0 Certificate Filed District Number R gister Number own or Village 1e r1g 1--c.AR _ 5601 ❑Burial Date Cemetery or Crematory Pine View Crematorium ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z ❑ Removal and/or Held • and/or Address 1'- Hold St. Mary's Cemetery Ulf- Date Point of 0 ❑Transportation Shipment O by Common Destination Cf Carrier Date Cemetery Address ❑ Disinterment ElReinterment 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 I— Remains_are Shipped, If Other than Above . • Address Oi~ tl3'' ▪ Permission is hereby granted to dispose of the human emains d scribed ove as incl. ated Date Issued ,y Registrar of Vital Statistics _a_g ,( d2--( �� ig ture) District Number 5601 Place ,,_-'=�SIG J } I certify that the remains of the decedent identified above were disposed of in accordance h this permit on: H, t�lh' Date of Disposition 111.0 Place of Disposition l Quaker Road Queensbury,NY 1 804 (address) l#,CO Ce (section) (lot number) ((_ (grave number) O Name of Sexton or Person in Charge of?remises (1nrlAxr J4.1 t(fl" rplease print) 14 Signature a ./J�`e� Title IREnifip)( (over) DOH-1555 (02/2004)