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Ingraham, John NEW YORK STATE DEPARTMENT OF HEALTH t 4 Igo Vital Records Section Burial - Transit Permit Name First Middle Last Sex ..' John Herbert Ingraham Male Date of Death Age If Veteran of U.S. Armed Forces, March 5, 2016 89 War or Dates F- Place of Death Hospital, Institution or W;;, City, Town or Village Glens Falls Street Address Glens Falls Hospital WManner of Death IL.]Natural Cause El Accident 0 Homicide ❑ Suicide riUndetermined ri Pending Circumstances Investigation W Medical Certifier Name Title W, Jennifer Stratton, MD Address 14 Manor Drive Queensbury, NY 12804 Death Certificate Filedg District Number Jt Register Ny City, Town or Village , l ❑Burial Date Cemetery or Crematory March 8, 2016 Pine View Crematorium Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed Removal and/or Held and/or Address ;. Hold 6 Date Point of ,❑Transportation Shipment CO': by Common Destination 0 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 I- Remains are Shipped, If Other than Above 2 Address w Permission is hereby granted to dispose of the human(emains de ribed ab ve as indic• ed. Date Issued Registrar of Vital Statistics , -1--) A ®'7.,�- _ ' / �� (signature) District Number Place 7 2e2� /� J'!J2-U I I certify that the remains of the decedent identified above wer- disposed of in accordance with is permit on: 1- W' Date of Disposition 03/08/2016 Place of Disposition rIwErvik�✓ ( 041,1043141 2 (address) W 0) Et (section) //�1`/ (lot number (grave number) 0 Name of Sexton or Person in Charge of Premises `hn number)._ z (please print) Ui Signature 6 447 Title at*in . (over) DOH-1555 (02/2004)