Dobler, Elizabeth NEW YORK STATE DEPARTMENT OF HEALTH 3 a 7
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Elizabeth Jane Dobler Female
Date of Death Age If Veteran of U.S. Armed Forces,
I- July 12, 2006 80 War or Dates
2 Place of Death Hospital, Institution or
W City, Town, or Village Fort Edward Street AddressFoRT HUDSON HEALTH CARE FAC.
0 Manner of Death I1 Natural Cause ❑ Accident ❑ Homicide ❑Suicide ❑ Undetermined ❑ Pending
W Circumstances Investigation
U Medical Certifier Name Title
W PHILIP J GARA JR. MD
a Address
327 Broadway, Fort Edward, NY 12828
Death Certificate Filed District Numbed Register Number
City, Town or Village Fort Edward �7�j� c_ib
Date Cemetery or Crematory
0 Burial Pine View Crematorium
Address
❑X Cremation Ouaker Road Oueensburv, NY 12804-
Date Place Removed
0 ❑ Removal and/or Held
- and/or Address
Hold
(11 Date Point of
0 ❑Transportation Shipment
d by Common Destination
0 Carrier
Date Cemetery Address
a ❑ Disinterment
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00284
Address
68 Main St., P. O. Box 67, Hudson Falls, New York 12839
Name of Funeral Firm Making Disposition or to Whom
0: Remains are Shipped, If Other than Above
w Address
Permission is he b ranted to dispose of the human re ins described above s indicated.
Date Issued 7/ p Registrar of Vital Statistic �../1 .-� (
-2
(signet re)
District Number5753 Place Fort Edward,New York
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 7/t 1 k L, Place of Disposition i n.2 ii,c ti, C- Y►..A-,ri „
2 (address)
Ui
N
0 (section) (lot number) (grave number)
O Name of Sexton Person in of Premises riCharge (, i S!i vfr
2 7
w (please print)
Signature d Title C t"A,e tr,C