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Kambach, Gary R ft S 0 NEW YORK STATE DEPARTMENT OF H EALTH Burial - Transit Permit Bureau of Vital.Records Name First Middle Last Sex Gary R.Kambach Male Date of Death Age If Veteran of U.S.Armed Forces, 01/04/2024 64 Years War or Dates H Place of Death Hospital,Institution or Z City,Town or Village Fort Ann Town Street Address 17 Needhamville Lane, Fort Ann Town, New York 12827 Ill p Manner of Death a Natural Cause ❑Accident ❑Homicide Suicide Undetermined Pending U I—ICircumstances Investigation C Medical Certifier Name Title Lynn Keil Coroner Address 1340 State Route 9,Lake George Town,New York 12845 Death Certificate Filed Town Of Fort Ann District Number Register Number City,Town or Village 5754 1 Burial Date Cemetery,Crematory or Facility Name 01/05/2024 Pine View Crematorium Entombment Address ©Cremation Queensbury Town,New York Donation g ElRemoval Date Place Removed and/or and/or Held H Hold Address VI 0 11 Date Point of (/)ElTransportation Q by Common Shipment Carrier Destination ElDisinterment Date Cemetery Address ElReinterment 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 3 Address CC W IL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/05/2024 Registrar of Vital Statistics Miranda 2ferringshaw(ECectronicatTy Signed) (signature) District Number 5754 Place Town Of Fort Ann I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I— W Date of Disposition f/4/ c,?i/ Place of Disposition i1;ft� V,s( u) CR.)-1}ci)i 2 i (address) W N CC (section) (lot number) (grave number) 8 Name of Sexton or Person in Charge of Premises i d>K e.Y S.v -. Z (please print) IU Signature / Title (f t"`7�01 DOH-1555(07/18)p 1 of 2 7 8 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#