Cameron III, John # 0 g
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
John A. Cameron,III Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 20,2013 51 War or Dates
I_ Place of Death Hospital, Institution or
Z City, Town or Village Albany Street Address 40 New Scotland Ave
QManner of Death ❑Natural Cause ❑Accident ❑Homicide �X Suicide ❑Undetermined n Pending
W Circumstances Investigation
w Medical Certifier Name Title
Ca John Keegan
Address
112 State Street,Albany,NY 12205
Death Certificate Filed District Number Register Number
City, Town or Village Albany /2/ ! ! 36'
❑Burial Date Cemetery or Crematory
El Entombment October 25,2013 Pine View Crematory
Address
®Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
ZO ❑Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
Nn Transportation Shipment
'p by Common Destination
Carrier
Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
I- Remains are Shipped, If Other than Above
M Address
W
w
a. Permission is hereby granted to dispose of the human remains described above as indic
Date Issued /0 'p2a 'f3Registrar of Vital Statistics t °t(/j�Ce, G 7/ ,"1"�J
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(signatur )
District Number to( Place Albany
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition to lWr3 Place of Disposition u„,,) L/f�vvi0('v—
2 (address)
W
CO
OC (section) /� (lot number)�" (grave number)
Op Name of Sexton or Pers n in Charge f Premises ` +�t J'»
Z ` (p ase print)
W Signature / L - Title CittNIRcOy'
9 r
(over)
DOH-1555(02/2004)