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Camfield, Richard NtVV YORK SLATE DEPARTMENT OF HEALTH if i..-5 Vital Records Section Burial - ransit Permit r° Name First Middle Last Sex Richard Joseph Camfield Male Date of Death Age If Veteran of U.S. Armed Forces, February 15, 2016 66 War or Dates ZPlace of Death Hospital, Institution or 1. City, Town or Village Glens Falls Street Address 14 Second St. Manner of Death m Natural Cause ❑ Accident ❑ Homicide n Suicide n Undetermined ❑ Pending Circumstances Investigation III; Medical Certifier Name Title C Darci Gaiotti-Grubbs, M.D Dr. Address 102 Park Street Glens Falls, NY 12801 Death Certificate Filed District Number Register Number City, Town or Village 5601 0`7 „,I:]Burial Date Cemetery or Crematory �' February 17, 2016 Pine View Crematorium ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed ❑ Removal and/or Held • and/or Address H; Hold GLENS FALLS CEMETERY Date Point of ty n Transportation Shipment `COI by Common Destination 0` Carrier Disinterment Date Cemetery Address ❑ Reinterment Date Cemetery Address 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 f Remains are Shipped, If Other than Above • Address Imo° Ui • Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued / 7 ) I t} Registrar of Vital Statistics UV & 4(Y"`'� J JL' (signature) District Number 5601 Place (1:,,v\a lc,\\\S , I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition 02/17/2016 Place of Disposition Quaker Road Queensbury,NY 12804 M (address) w (L' (section) i (lot number� (grave number) 0` Name of Sexton or Person in Charge o remises [,//hs y` °Z, ���/�� (Please print) � W' Signature i� Title ce4141-61- (over) DOH-1555 (02/2004)