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Nettleton, Ralph Bayard , NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex 1 Ralph Bayard Nettleton Male Date of Death Age If Veteran of U.S.Armed Forces, 12/26/2020 76 Years War or Dates 1... Place of Death Hospital,Institution or 1 Z City,Town or Village Kingsbury Town Street Address 18 Lori Lane,Kingsbury Town,New York 12839 W Manner of Death ©Natural Cause El Accident0 Homicide Suicide Undetermined 0 Pending Circumstances Investigation 11 W Medical Certifier Name Title O Mary Stein NP Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number I City,Town or Village Kingsbury Town 5762 40 1' 0 Burial Date Cemetery,Crematory or Facility Name d 12/29/2020 Pine View Crematorium ❑Entombment Address ElCremation Queensbury Town,New York ❑Donation Z ❑Removal Date Place Removed and/or and/or Held F N Hold Address 0 0. Date Point of Cl) Li Transportation p by Common Shipment Carrier Destination El Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67, Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped,If Other than Above -- Address CC W EL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/28/2020 Registrar of Vital Statistics Cynthia cBarthn(ECectronicaCCy Signed) (signature) District Number 5762 Place Kingsbury Town, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition CZ,50 -2o2o Place of Disposition I ,)i P,L,�� C„ e 4 ivW (address) W CCCC (section) ( umber) (grave number) 0 Name of Sexton or Per in C rge of Premises �'`1 l4 �a" c'l' (please print) jj_ u1 Signature Title 4'� e m de a`4,c4 e/ DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 014 3 5 0 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#