Purdy, Ronald NEW YORK STATE DEPARTMENT OF HEALTH :to si
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Vital Records Section BurialTransit Permit
Name First Middle Last Sex
Ronald Floyd Purdy Male
441 Date of Death Age If Veteran of U.S. Armed Forces,
June 23, 2015 79 War or Dates
Place of Death Hospital, Institution or
MCity, Town or Village Fort Ann Street Address 21 George Street
Manner of Death Natural Cause ❑ Accident E Homicide ❑ Suicide ❑ Undetermined ❑ Pending
0LIICircumstances Investigation
W Medical Certifier Name Title
in Daniel Way, M.D Dr.
Address
North Creek Health Ctr Warrensburg, NY
,ice, Death Certificate Filed District Number aoc)\ gRe i rNu ber
City, Town or Village I
❑Burial Date Cemetery or Crematory
June 26, 2015 Pine View Crematorium
❑Entombment Address
"`®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑
Removal and/or Held
and/or Address
Hold
a Date Point of
❑Transportation Shipment
by Common Destination
0 Carrier
Date Cemetery Address
❑ Disinterment
❑ 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
Remains are Shipped, If Other than Above
Address
IX'
W_
P" Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 6 /2 b 1 1S Registrar of Vital Statistics WQ.k.A.,Prvi2_ \..A.)
(signatu
District Number 5 60 i Place 6 (QA^c, k \ S /\.)
I certify that the remains of the decedent identified above ere disposed of in accordance with this permit on:
ne u.Pw C reMcde,,
w Date of Disposition 06/26/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
e= (section) (lot number) (grave number)
. -- ` r /
Name of Sexton or Person in C arge of Premises . frr,o`tk i y ne
z, ; (please prinp
' Signature Title Cfrnae'lory 055 '
(over)
DOH-1555 (02/2004)