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Holman, Kayden 2SC1NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit, Name First Middle Last hex Kayden Matthew Holman Male Date of Death I Age If Veteran of U.S. Armed Forces, 4/2/2016 Stillborn War or Dates 1.-" Place of Death Hospital, Institution or z City, X�YJ III losm CX Glens Falls Street Address Glens Falls Hospital . Manner of Death n Natural Cause ©Accident Homicide 0 Suicide ri Undetermined Q Penang Circumstances Investigation ,l Medical Certifier Name - Title 0 Address ` 100 Park St. , Glens Falls, NY 12801 Death Certificate Filed District Num r/ Register r i' Glens Falls 6 City, � xxt�t 4/ < �� ,' . O$urial Date Cemetery or Cre matory 04/05/2016 Pine View Crrema orium E,;, ❑Entombment Address < r (BCremation Quaker Road,Queensbury, NY 12804 Date Place Removed Z Removal and/or Held Q u and/or Hold Address wit- C� Date [ Point of `El3 L_.1 Transportation Shipment by Common Destination Carrier E. ©Disinterment Date CemeteryAddress Date Cemetery Address . 0 Reinterment Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home, Inc., 00281 Address PO Box 67, Hudson Falls, NY 12839 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address t Permission is hereb granted to dispose of the human remains de ;hod ab ve n ioated. Date Issued QD /Z�j l�Registrar of Vital Statistics �, (signature) District Number 5(e(}/ Place ke,--#; ,`/, ti y H I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z. MI Date of Disposition A(" ?-l(p Place of Disposition f�ito_v re-4) GlamA-I-0 r� (address) pCC (section) (lot n ber) (grave number) Name of Sexton or ' Charge f Premises .A ,, J i GZ.,1 t a-e'k� a z (please print) 41 Signature Title `=`e-/''4-/, (over) DOH-1555 (02/2004)