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Depew, Camden NEW YORK STATE DEPARTMENT OF HEALTH ta rI Vital Records Section Burial - Transit Permit ''': Name First Middle Last I Sex 114 Camden Scott Depew male ,, Date of Death Age If Veteran of U.S. Armed Forces, `¢ 3. Dec. 13, 2013 0 War or Dates _0_ • w(t*. Place of Death Hospital, Institution or . City, TfteRiikkAtige Glens Falls Street Address Glens Falls Hospital ' Manner of Death© Natural Cause � Accident ❑Homicide ❑ Suicide Undetermined Pending u; Circumstances Investigation Medical Certifier Name Title ' ' Danielle (',aef zen MD Address 90 South Si-., Glens Falls, NY 12801 j Death Certificate Filed District Number Reciter Number _, City, Ttbagax Glens Falls 5601 " ❑Burial Date Cemetery or Crematory ` ` . � - 17, 2013 Pine View Crematorium Entombment Address 0 ceRemation Tn of Quensbury, NY Date Place Removed Z Removal and/or and/or Held Hold Address VI Date Point of Transportation Shipment by Common Destination a Carrier ' Ei Disinterment Date Cemetery Address ,,^ ., Ei Reinterment Date Cemetery Address Permit Issued to Registration Number }. Name of Funeral Home Carleton Funeral Home, Inc. 00281 xeli '° Address Im 68 Main St., Hudson Falls, NY 12839 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above al Address llf a'° Permission is hereby granted to dispose of the human remains describe bove as "ndic w - Registrar of Vital Statistics ,& 7. Date Issued �� �7 ZUl3 9 4.-=,, (signature) District Number Place 5601 city of Glens Falls, NY t I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: a Date of Disposition P-4-13 Place of Disposition Zoklio Cam,— (address) w. (section) (#I number) (grave number) Name of Sexton or Person in C arge of P emises ( Lfgl(a.. Si•c G (please punt) Signature i' Title c1J ' rcAL (over) DOH-1555 (02/2004)