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Kuba, William Charles Pf 3 g-) NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex William Charles Kuba Male Date of Death Age If Veteran of U.S.Armed Forces, 04/30/2021 53 Years War or Dates H Place of Death Hospital,Institution or Z City,Town or Village Hudson Falls Village Street Address 19 Martindale Avenue,Hudson Falls Village,New York 12839 UJI p Manner of Death ©Natural Cause El Accident El Homicide 0 Suicide ❑Undetermined El Pending W Circumstances Investigation W Medical Certifier Name Title CI Robert Lemieux Coroner Address 415 Lower Main Street,Hudson Falls Village,New York 12839 Death Certificate Filed District Number Register Number City,Town or Village Hudson Falls Village 5726 9 0 Burial Date Cemetery,Crematory or Facility Name 05/03/2021 Pine View Crematorium ❑Entombment Address IKICremation Queensbury Town,New York ❑Donation Z ❑Removal Date Place Removed and/or and/or Held F- Hold Address CO 0 Date Point of co ❑Transportation Shipment p by Common Carrier Destination 1:1Disinterment 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 IH Remains are Shipped,If Other than Above a Address CC LU 0. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/03/2021 Registrar of Vital Statistics Cynthia ABardin(ECectronica1TySigned) (signature) District Number 5726 Place Hudson Falls Village, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: IH � Z Date of Disposition 51H I t l Place of Disposition 4L 40 av-- W (address) LU N Cr (section) lot number) (grave number) G Name of Sexton or Person in Charge of P ises I t `''' S�..4 it Z (pleas print) Ill Signature s Title DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 0 1 75 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# /`