O'Leary, Ryan NEW YORK STATE DEPARTMENT OF HEALTH It- 3/3
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Ryan Mantle O'Leary Male
Date of Death Age If Veteran of U.S. Armed Forces,
June 21, 2012 36 War or Dates
Place of Death Hospital, Institution or
w City, Town or Village Kingsbury I Street Address Notre Dame Extention, Side of Road
W' Manner of Death❑ Natural Cause ❑ Accident 0 Homicide El ❑ Undetermined ❑ Pending
U Circumstances Investigation
W Medical Certifier Name Title
CI Max Crossman MD,
Address
North St. Granville, NY 12832
Death Certificate Filed District Number Register Number
City, Town or Village S 7 L
❑Burial Date Cemetery or Crematory
June 22, 2012 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date ' Place Removed
z ❑ Removal and/or Held
and/or Address
1 Hold
0) Date Point of
p„ ❑Transportation Shipment
0) by Common Destination
3 Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Reinterment
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
I— Remains are Shipped, If Other than Above
2 Address
W;
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 6',Zv `
o,d as Registrar of Vital Statistics .- t-e= m <--,--c--
(signature)
District Number 5 ?(o a Place i cr-t_a.,-‘ ,I,L,,,_./,,,7
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition c,(16 f(1 Place of Disposition 1?riUcco 64v-I0fiu`-
2 (address)
W
0)
ce (section) (lot number) (� (grave number)
0 Name of Sexton or Perso in Charge of emises t� '`�`�t` { Jfk'd�
(K lease print)
W Signature Title
C4t A►rttj YL,
--�
(over)
DOH-1555 (02/2004)