McIntosh, Norma NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
„ Name First Middle Last Sex
11
Norma Ruth McIntosh Male
Date of Death Age If Veteran of U.S. Armed Forces,
F December 12, 2006 71 War or Dates
2 Place of Death Hospital, Institution or
W City, Town, or Village Glens Falls Street AddressGlens Falls Hospital
G Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide Suicide ❑ Undetermined ❑ Pending
W Circumstances Investigation
o Medical Certifier Name Title
W Dr. Orlando J. Martelo, M.D. Dr.
0 Address
102 Park St., Glens Falls, NY 12801
Death Certificate Filed District Number Register N►.mber
City, Town or Village Glens Falls 5U01 LQ(at
Date Cemetery or Crematory
❑ Burial December 14, 2006 Pine View Crematorium
Address
❑x Cremation Ouaker Road Oueensburv, NY 12804-
Date Place Removed
0 ❑ Removal and/or Held
and/or Address
Hold
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
Permission is hereby ranted to dispose of the human r ains described bove as i •'cated.
Date Issued / /,j �i Registrar of Vital Statistics �'�Q�Q� / /.�G71'C
� (signature)
District Number 3�,j/ 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:
Z
W Date of Disposition ia// 'bL Place of Disposition -12m.v14t.„ Cce&p C.t art,,.,,
2 (address)
W
N
re (section) t number) (grave number)
0
O Name of Sexton or Person i Charge of Premises C I r,s 2 41, 'l`-
2 (please print)
w ( Title Cr As lti-
Signature