Dullahan, June NEW YORK STATE DEPARTMENT OF HEALTH 3sS D
Vital Records Section ,l Burial - Transit Permit
.4
1 Name First Middle' ♦ Last Sex
June Bakeman Dullahan Female
Date of Death Age If Veteran of U.S. Armed Forces,
I• August 31, 2006 92 War or Dates
2 Place of Death Hospital, Institution or
W City, Town, or Village Glens Falls Street AddressGlens Falls Hospital
0 Manner of Death ❑ Natural Cause ❑ Accident ❑ Homicide ❑Suicide ❑ Undetermined ❑ Pending
W Circumstances Investigation
() Medical Certifier Name Title
W JOHN G DIER MD
d Address
453 Dixon Road Queensbury, NY 12804
Death Certificate Filed District Number 6, Register Numper j 9City, Town or Village Glens Falls tt
Date Cemetery or Crematory
❑ Burial Sectember 1, 2006 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
5 ❑ Disinterment
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00283
Address
H 68 Main St., P. O. Box 67, Hudson Falls, New York 12839
Name of Funeral Firm Making Disposition or to Whom
x Remains are Shipped, If Other than Above
w Address
O.
Permission is hereby granted to dispose of the huma remains describe bove as I icate .
Date Issued 9./ i 1 0 , Registrar of Vital Statistics
(signature)
District Number S 6 0 I Place Glens Falls,New ork
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
wDate of Disposition 's-I- Gt. Place of Disposition .P,ncvicr, Cra,,.<-F v,r1 ✓,Z
W (address)
U)
0 t (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises C L(' ) J.P tinr q
Z (please print)
W
Signature al, Title Cr -oc-