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Davis, Matthew NEW YORK STATE DEPARTMENT OF HEALTH ` ' #U` Vital Records Section Burial - Transit Permit Name First Middle Last Sex 1` Matthew Ryan David Male Date of Death Age If Veteran of U.S. Armed Forces, August 26, 2016 25 War or Dates Place of Death- -Hospital, Institution or City, Town or Villa. Hudson Falls Street Address 66 King Avenue uManner of Dea © Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending Circumstances Investigation LU Medical Certifier Name Title Id David Shaffer, M.D Address w 43 New Scotland Ave. Albany, NY 12208 i Death Certificate . d District Number Register Number City, Town or illa U u sn, Fa.th Sn),(c) o�1 ,,'❑Burial ate Cemetery or Crematory August 30, 2016 Pine View Crematorium 0 Entombment Address ®Cremation Quaker Road Queensbury,NY 12804 Date Place Removed ❑ Removal and/or Held vand/or Address F-' Hold lala Date Point of ❑Transportation Shipment i', by Common Destination ;, Carrier Disinterment Date Cemetery Address ❑ Reinterment Date Cemetery Address y t' • 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 Remains are Shipped, If Other than Above Address U Permission is hereby granted to dispose of the human remains scribed above as indicated. 00 Date Issued ,j-,aa,a0/6 Registrar of Vital Statistics . � _.)©1 n < �, (signature) District Number _5` (2(Q Place .so-r: N-c S 0 I certify that the remains of the decedent identified abo were disposed of in accordance with this permit on: k fa Date of Disposition 08/30/2016 Place of Disposition Quaker Road Queensbury,NY 12804 (address) (section) (lot number) (grave number) IttilL, Name of Sexton or Person in Char a of Premises 4pAr i `�"�,-(please print) T Signature Title "�"�,�f�',it (over) DOH-1555 (02/2004) I