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Conklin, Zechariah If NEW YORK STATE DEPARTMENT OF HEALTH • Vital Records Section Burial - 1 Transit Permit Name First Middle Last Sex Zechariah John Conklin Male Date of Death F Age If Veteran of U.S. Armed Forces, 04/03/2016 Stillborn War or Dates t=•. Place of Death Hospital, Institution or W City, 'retkfi XiK J XX Glens Falls ' Street Address Glens Falls Hospital Manner of Death ryl tzLi Natural Cause Accident D Homicide ©Suicide Q [Undetermined Pending Circumstances Investigation la Medical Certifier Name Title Q Allison Herrick CEO Address 45 Hudson Ave,Glens Falls NY 12801 Death Certificate Filed - District District Num �� Register tier City, '1i C tXVN a Glens Falls t ❑Burial Date Cemetery or Crematory 04/06/2016 Pine View Crematorium DEntombment Address ` Cremation Quaker Rd, Queensbury, NY 12804 . Date Place Removed 4❑Removal and/or Held and/or Address Hold fp VD Date Point of A []Transportation , Shipment ct by Common Destination Carrier El Disinterment Date Cemetery Address [J Reinterment f Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home, Inc. 00281 Address 68 Main St. Hudson Falls, NY 12839 Name of Funeral Firm Making Disposition or to Whom L Remains are Shipped, If Other than Above a Address tu t. Permission is hereby granted to dispose of the human remains descri ed sibo as cated, Date Issued Q�1(5G�? G Registrar of Vital Statistics (signature) District Number ‘2p/ Place oA AG/ ,0y 1 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: IiI Date of Disposition 2.j-7,/(n Place of Disposition 77 el)t Z 12/77i.,1 ry 2 (address) ili f/N CC (section) (lot n ber) ii (grave number) a Name of Sexton or Pe har a of Premises J .- /i4.vi H'lavu4- 2 (please print) td Signature Title Griya4 i (over) DOH-1555 (02/2004)