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Condon, Bentley NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Bentley James Condon Male Date of Death Age If Veteran of U.S. Armed Forces, June 11, 2016 'trvn4 War or Dates Z Place of Death Hospital, Institution or W City, Town or Village Glens Falls Street Address Glens Falls Hospital WManner of Death ❑Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined Pending W Circumstances Investigation W.. Medical Certifier Name Title Ci Michael Sikirica MD, Address 50 Broad Street Waterford, NY 12188 Death Certificate Filed District Number Register Number City, Town or Village 5 6 Q i 30 Li 0 Burial Date Cemetery or Crematory June 15, 2016 Pine View Crematorium ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z ❑ Removal and/or Held O and/or Address Hold CO Date Point of a ❑Transportation Shipment coby Common Destination 3 Carrier Date Cemetery Address El Disinterment Date Cemetery Address ❑ Reinterment 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 IX W ii. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued tit 5 / /6 Registrar of Vital Statistics l ,`y� k.A.)--A,-- (signature) District Number 5 60 I Place (� Cs 5 1 1 S, eti y I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: il. PaeLe.Ur Q. ) tj/ s 44 rY w Date of Disposition 06/%12016 Place of Disposition Quaker Road Queensbury,NY 12804 M` (address) W 0) 11 (section) (lo number) (grave number) CX Name of Sexton or r .n i Charge of Premises 4 L.-14.-it va c-4-1 ?„ �ji (please pant) W' Signature / , Title 4.re444✓401 / (over) D( 55 (02/2004)