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Ingram, Daniel NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial .. Transit Permit Name First Middle Last Sex Daniel John .mayahaaii-- pwt.' Male Date of Death TAge 1 If Veteran of U.S. Armed Forces, 10/18/2016 i 45 I War or Dates I-- Place of Death Hospital, Institution or Z City, Town or Village Saratoga Springs l_Street Address Saratoga Hospital ill—ll Nat__ .______- Manner of Death Natural Cause Accident C Homicide ©Suicide Ti Undetermined ri Pending W Circumstances Investigation uj Medical Certifier Naive Title 0 N. Balasnbraman MD Address 40 McMaster St., Ballston, Spa, NY Death Certificate Filed I District Number `s 1 1 Regist r� r City,Town or Village Saratoga Springs j '1 .L.� 0Burial Date Cemetery or Crematory 10/21/2016 Pine View Crematorium ]Entombment Address :Cremation Tn of Queensbury, NY - . Date j Place Removed Zi Removal and/or Held w and/or Address — Hold tIL 1 4 Date Point of a0 Transportation l Shipment 0 by Common Destination Carrier ) Disinterment Date Cemetery Address 1 ❑Reinterment Date Cemetery Address I Permit Issued to I Registration Number Name of Funeral Home Carleton Funeral Home, Inc. jC 00281 Address 68 Main St, Hudson Falls, NY 12839 - Name of Funeral Firm Making Disposition or to Whom I-= Remains are Shipped, If Other than Above Address -it 12' Permission is hereby granted to dispose of the human remai rib ab a dicated Date Issued 10.. �.. egistrar of Vital Statistics (signature) District Number ®"I5L.4(.. Place `�Orako. Sporki-v.1.5 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on, Cr . .WW. Date of Disposition JO 1Z5-iN. Place of Disposition 4?1,-1/04.....- Grly.. W (address) U) CC (section) (lot number (grave number) 0 Name of Sexton or Person in Charge of Premises 4 /.4t J` Z ( tease print) Signature2 Title GG ''''Vt1 (over) DOH-1555 (02/2004)