Corlew, Marjorye NEW YORK STATE DEPARTMENT OF HEALTH ' C)
Vital Records Section 1Burial - Transit Permit'
Name First Middttr Last Sex
Marjorye Elizabeth Corlew Female
Date of Death Age If Veteran of U.S. Armed Forces,
1- December 9, 2006 97 War or Dates
2 Place of Death Hospital, Institution or
W City, Town, or Village South Glens Falls Street Addressl6 Jackson Ave
0 Manner of Death E Natural Cause ❑ Accident ❑ Homicide El Suicide ❑ Undetermined ❑ Pending
W Circumstances Investigation
(j Medical Certifier Name Title
W THOMAS F KANDORA MD
0 Address
7240 Upper Broadway, Fort Edward, NY 12828
e Death Certificate Filed District Number Register Number
.4 City, Town or Village South Glens Falls
Date Cemetery or Crematory
❑ Burial December 12, 2006 Pine View Crematorium
Address
0 Cremation Ouaker Road Oueensburv, NY 12804-
Date Place Removed
0 ❑ Removal and/or Held
- and/or Address
Hold
0 Date Point of
0 ❑Transportation Shipment
CL by Common Destination
0 Carrier
Date Cemetery Address
a ❑ Disinterment
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00283
Address
68 Main St., P. O. Box 67, Hudson Falls, New York 12839
• Name of Funeral Firm Making Disposition or to Whom
te Remains are Shipped, If Other than Above
w Address
O.
Permission is hereby granted to dispose of the human rema' s escribed above as indicated.
Date Issued lam/2/0(0 Registrar of Vital Statistics e.r%
/ f (signature) 1&LCI---
i.District Number '730�7 Place South Glens Falls,New York
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition 1) I I3/0(place of Disposition (addre se V I'C ' C. revv,a f O r y
w
U)
0 C' (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises C p II O.O. r
W (please print)
b I
Signature_ �� Title C r w1 cN to C