Pearson, Margaret NEVI/YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit Li3 7
+ Name First Middle Last Sex
41
Margaret Lucille Pearson Female
Date of Death Age If Veteran of U.S. Armed Forces,
F October 12, 2006 90 War or Dates
2 Place of Death Hospital, Institution or
W City, Town, or Village Amsterdam Street Addressst. Nary,s Hospital
G Manner of Death Natural Cause El Accident El Homicide 0Suicide El Undetermined lip Pending
W Circumstances Investigation
() Medical Certifier Name Title
Ill M.A. Khan M.D.
C Address
425 Guy Park Avenue, Amsterdam, New York
Death Certificate Filed District Number Register Number
City, Town or Village Amsterdam 2801 282
Date Cemetery or Crematory
El Burial October 13, 2006 Pine View Crematorium
Address
XX Cremation Ouaker Road Oueensburv, NY 12804-
Date Place Removed
0 0 Removal and/or Held
- and/or Address
Hold
0 Date Point of
p E Transportation Shipment
0 by Common Destination
0 Carrier
Date Cemetery Address
Q Disinterment
D
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 02043
Address
136 Warren St., P.O. Box 612, Glens Falls, New York 12801
Name of Funeral Firm Making Disposition or to Whom
e: Remains are Shipped, If Other than Above
w Address
0.
Permission is hereby granted to dispose of the human remains describe aI ve as dicated.
Date Issued 10/13/06 Registrar of Vital Statistics
p.it.u. ea
(signature)
District Number
2801 Place Amsterdam,New York
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
w Date of Disposition to%it. /(;b Place of Disposition P,nevIt..,, C titc.>r ,u/.-
2 (address)
V)
ft (section) 1 (19$number) (grave number)
O Name of Sexton or Person in Charge of Premises Ci r,s SQ,, 4-
2 g `) (please print)
Signature ( / Title Cre,, +,,X