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Austin, Baby Boy NEW YORK STATE DERARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex IP Baby Boy Austin Male Date of Death Age If Veteran of U.S. Armed Forces, December 22, 2015 0 War or Dates 2 Place of Death Hospital, Institution or City,X AGDtb��itStl�1g ( Glens Fallstit Street Address Glens Falls Hospital Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending tom'. Circumstances Investigation 0 itit Medical Certifier Name Title Edward Denious, M.D ` ' Address x 45 Hudson Ave. Glens Falls, NY 12801 rDeath Certificate Filed ,�. District Number Register Number x; City, Town or Village (3 l e,61 f I (J 5601 ❑Burial Date Cemetery or Crematory *4, December 28, 2015 Pine View Crematorium ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed a❑ Removal and/or Held and/or Address E Hold Date Point of ws❑Transportation Shipment by Common Destination Carrier 0 Disinterment Date Cemetery Address ,gin, ❑ 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 w W Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued t 2.r 22-1 I S Registrar of Vital Statistics W c1v Q-A— kA)A' -) Qt (signature) District Number 5601 Place `;2 'S FU ‘ \S l 1J y /2-so I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 1 Z.-'L.e4,-l5— pm''L v-•rr4t! A4.1 W" Date of Disposition t2/2812045 Place of Disposition Quaker Road Queensbury,NY 12804 2. (address) La CO fit (section) (lot number) (grave number) o' Name of Sexton P so in Charge of Premises ,, t..,,L c,k 6G-m�44e, (please print) Signature Title � 4V- (over) DOH-1555 (02/2004)