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Cain, Ronald NEW YORK STATE DEPARTMENT OF HEALTH ' ` % 't 1 CI 5. Vital Records Section Burial - Transit Permit Name First Middle Last Sex Ronald Jay Cain Male Date of Death Age g If Veteran of U.S. Armed Forces, April 14, 2011 60 War or Dates Vietnam Place of Death Hospital, Institution or rt City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death Undetermined Pending Natural Cause Accident Homicide Suicide Circumstances Investigation Medical Certifier Name Title Mark Weidner, M.D. Dr. Address 102 Park Street Hudson Falls, NY 12839 Death Certificate Filed District Number5�/,� I ' Register Number City, Town or Village V 1 0 Burial Date Cemetery or Crematory April 18, 2011 Pine Vew Crematorium 0 Entombment Address ©Cremation Queensbury,NY 12804 Removal Date Place Removed and/or Held and/or Address Hold Date • Point of Transportation Shipment by Common Destination Carrier 0 Disinterment Date Cemetery Address Date Cemetery Address 0 Renterment Permit Issued to Number , Name of Funeral Home Carleton Funeral Home, Inc. 00276 Registration 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 � Remains are.Shipped, If Other than Above Address Permission is hereby granted to dispose of the human remains descrri)Vve ind'6 Date Issued 0 Registrar of Vital Statistics _J (signature) District Number 5 O/ Place 67e , `A, ,G)/ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition LI-11-I I Place of Disposition -inctl iC w C., o►c f v t i vt.. ae (address) (section) ,7 (lot number) (grave number) Name of Sexton or P rson in Charg of Premises i h(.;+u1,r- e 4,414- 1 I (please print) Signature 1. k. Title CPO)CAC, (over) DOH-1555 (02/2004)