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Bolster Sr, Gary NEW YORK STATE DEPARTMENT OF HEALTH # 111 Vital Records Section Burial - Transit Permit ti Name First Middle Last Sex Gary Lynn Bolster, Sr. Male Date of Death Age If Veteran of U.S.Armed Forces, 4,4 December 26, 2016 62 War or Dates- Vietnam I Place of Death Hospital, Institution or W" City, Town or Village Lake George Street Address 14 Hammond St, Cf Manner of Death rrlI Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending i l` Circumstances Investigation L11= Medical Certifier Name Title, a Address o- Death Certificate Filed District Number Register Number City, Town or Village IV 0 Burial Date Cemetery or Crematory .444 December 28, 2016 Pine View Crematorium ��,❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed 74 Removal ❑ and/or Held and/or Address H Hold Date Point of O. 0 Transportation Shipment by Common Destination i Carrier '' Date Cemetery Address ❑Disinterment IllReinterment Date Cemetery Address - �; Permit Issued to Registration Number Xitt Name of Funeral Home Carleton Funeral Home, Inc. 00281 ,r _. Address x ' 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 tr `,,,,,.va Permission is hereby granted to dispose of the human rem escribed abo ash i�diicated. Org Registrar of Vital Statistics C '1C ', G Yg� '-"�r Date Issued��,�� —�(0 9 signature) District Number / ( Place 41._oicsryt,c_i Qr v I 11 I certify that the remains of the decedent identified above were disposed of in acc dance with this permit on: la Date of Disposition 12/28/2016 Place of Disposition Quaker Road Queensbury,NY 12804 la p P (address) Ui .. . W (section) /. (lot number (grave number) .,0,;. Name of Sexton or Person in Charge of Premises �l�r, ,- 3144* (please print) to Signature Title I MI1/VQ (over) DOH-1555 (02/2004)