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Coltrain, Ashley NEW YORK STATE DEPARTMENT OF HEALTH` ' ' i n b1 Vital Records Section Burial - Transit Per it 11 Name First Middle Last Sex Ashley Elizabeth Coltrain Female Date of Death Age If Veteran of U.S. Armed Forces, September 6, 2017 18 War or Dates Lt Place of Death Hospital, Institution or City, Town or Village Hudson Falls Street Address 11 North Street Manner of Death❑Natural Cause ❑ Accident X❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending Circumstances Investigation 10 Medical Certifier Name Title Michael Sikirica MD, Address 50 Broad Street Waterford, NY 12188 Death Certificate Filed District Number Register Number City, Town or Village $7.. 4 / 9 ❑Burial Date Cemetery or Crematory September 8, 2017 Pine View Crematorium ' ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed ❑ Removal and/or Held 0and/or Hold Address r Date Point of wi.❑Transportation Shipment by Common Destination O Carrier Date Cemetery Address El Disinterment ❑ Reinterment Date Cemetery Address 4 Permit Issued to Registration Number MA Name of Funeral Home Carleton Funeral Home, Inc. 00281 Address 41- Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above al Address VI Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued q /* "7 Registrar of Vital Statistics t-iJ4t-a- G / f M (signature) District Number S 7) 4, Place I' /I 4 c { /lei WI h �C //S I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 1-" W' Date of Disposition 09/08/2017 Place of Disposition Quaker Road Queensbury,NY 12804 2' (address) W, (section) / (lot number) (grave number) Name of Sexton or Person in Charge of Premises G�N �1.,, 9" z, /, (p ase print) >W Signature f.� Title `1140 tnit (over) DOH-1555 (02/2004)