Cook, Marnalee NEW YORK STATE DEPARTMENICOF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Marnalee Cook Female
Date of Death Age If Veteran of U.S. Armed Forces,
J-• ary 12, 2017 67 War or Dates
P -/., o •e-th Hospital, Institution or
W, Cit f ow, •r Village Y 1 h G S b y to C Street Address .1028 Dix Ave., Lot 18 ,
Wanner of Death 0 Natural Causel ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
0 Circumstances Investigation
W; Medical Certifier Name Title
G1 David Foote Md,
Address
Rt 4 Hudson Falls, NY 12839
Dea e cate Filed District Number Register Number
, Ci , Town Village ,�t n �{ 5 b r 5762 G :
❑Burial Date J Cemetery or Crematory
January 13, 2017 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
a and/or Address
F,- Hold
CO Date Point of
11, ❑Transportation Shipment
N by Common Destination
t Carrier
❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address •
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
2 Address
W
Permission is hereby granted to dispose of the human rema' described above as indicated.
Date Issued 1- 17- (7 Registrar of Vital Statistics� 1," ��- --
(signature)
74
7
7
__
2 District Number 5762 Place 2k s-I
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 01/13/2017 Place of Disposition Quaker Road Queensbury,NY 12804
2 (address)
W
U?;
[e. (section) &ctEt,i
(lot number) (grave number)
Name of Sexton or Person in Charge of Premises /AL/Dt
z , lease print)
W Signature a - Title (REMf�F �-
(over)
DOH-1555 (02/2004)