Belden, Harold NEW YORK STATE DEPARTMENT OF HEALTH ' `* # 532_
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Harold Arthur Belden Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 4, 2012 75 War or Dates After 1/31/55
• Place of Death Hospital, Institution or
City, Town or Village Kingsbury Street Address
Wf Y, 9 9 ry
Manner of Death Natural Cause ❑ Accident 0 Homicide E Suicide niUndetermined ri L. Pending
0' Circumstances Investigation
W" Medical Certifier Name Title
Ct
1'1 ( ia9.M 60-7.tis
Addresg 1 S_,_/
ON�.ce�.1 , P o f/
Death Certificate Filed District Number Register Number
City, Town or Village t,2 1 5'7 L,D-- 1 f
10 Burial Date Cemetery or Crematory
October 10, 2012 Pine View Crematorium
v 0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
t p and/or Address
E Hold
0 Date Point of
a. ❑ Transportation Shipment
3 by Common Destination
Carrier
0 Disinterment
Date Cemetery Address
* 0 Reinterment Date Cemetery Address
r
• Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
it' 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
H Remains are Shipped, If Other than Above
,2 Address
CC
LU
11• "" Permission is hereby granted to dispose of the human remains described above as indicated.
- Registrar of Vital Statistics
Date Issued Jo -• !�. �/�- 9 ! '�- t'144--/P--
(signature)
District Number ��� Place uf,� r� / .,444, i hf� 1q g3
i—rx
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W^' Date of Disposition ,o l ii/i2. Place of Disposition Zt..Ukw (.tmc driv.-
- (address)
W:
re (section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises
��t�� � "K
(please print)
W', Signature Title C 14 t�LQif�.
(over)
DOH-1555 (02/2004)