Coltrain, Carolea NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Carolea L. Coltrain Female
Date of Death Age If Veteran of U.S. Armed Forces,
August 27, 2017 40 War or Dates
of Death Hospital, Institution or
LW Town or Village Glens Falls Street Address Glens Falls Hospital
CI Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
CI Michael
Michael Sikirica MD,
Address
50 Broad Street Waterford, NY 12188
Doh Certificate Filed _ District Number j Register Number
y Ci ,/Town or Village (..1 L n s I- ,C k 5 D Q i t^( (� O
Burial Date Cemetery or Crematory
September 5, 2017 Pine View Crematorium
1 ❑Entombment Address
" ®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z r-i Removal and/or Held
and/or Address
Hold
Date Point of
I ❑Transportation Shipment
{/); by Common Destination
C_ Carrier
Date Cemetery Address
El Disinterment
Date Cemetery Address
❑ Reinterment
'''A Permit Issued to Registration Number
v. 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
b: Remains are Shipped, If Other than Above
2 Address
:r
C' Permission is hereby granted to dispose of the human remains described above as indicated. ,c
tDate Issued al 3d1 2�'r7 Registrar of Vital Statistics WC , --Q �- �/
(signature)
District Number 56 0 Place 6 L,Ns c \ \S U .,` t�
I certify that the remains of the decedent identified above were d' posed of in accordance with this permit on:
p7 tie.v/Zvi 6-co-sn 4,4,y
Date of Disposition 09/92017 Place of Disposition Quaker Road Queensbury,NY 12804
2 (address)
w'
0)
W, (section) (lot number) (grave number)
0 Name of Sexton o Per in Charge of Premises - L.I-1 r.4't 64.-011U/ sa
Z (please print)
W Signature ✓ Title e.,!'Q rr+-l.� --
(over)
DOH-1555 (02/2004)