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Burns, Annette NEW YORK STATE DEPARTMENT OF HEALTH f . , t b 3 Burial Vital Records Section - Transit Permit Name First Middle Last Sex Annette Marie Burns Female Date of Death Age If Veteran of U.S. Armed Forces, August 21, 2017 52 War or Dates ZPlace of Death Hospital, Institution or LLL; City, Town or Village Saratoga Springs Street Address Mary's Haven CI Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending W` Circumstances Investigation W; Medical Certifier Name Title CI Chas Yang, M.D Dr. Address 102 Park St. Glens Falls, NY 12801 Death Certificate Filed �- District Number Register Number Bit )Town or Village cC,,� Oc2 urial Date Cemetery or Crematory August 24, 2017 Pine View Crematorium 0 Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed IIIRemoval and/or Held j and/or Address F Hold CODate Point of eL 0 Transportation Shipment _ by Common Destination O Carrier Date Cemetery Address El Disinterment Date Cemetery Address ❑ Reinterment Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home, Inc. 00281 Address Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839 Name of Funeral Firm Making Disposition or to Whom I— Remains are Shipped, If Other than Above M Address CC d' Permission is he ebyt g anted to dispose of the human remains descri d aDate Issued ' • � I"") Registrar of Vital Statistics 4., 1 , bcp s- 1 (signature) District Number LA Sc Place ) fk• /,,q, 9E i , ,..) I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition 08/24/2017 Place of Disposition Quaker Road Queensbury,NY 12804 M (address) W+ Cl, (section) ll(lot number) (grave number) O Name of Sexton or Person in Charge of Premises 64^t:s14r �S a»A4g- a (plea a print) W Signature jfr Title trai 1i. (over) DOH-1555 (02/2004)