Corlew, Carol NEW YORK STATE DEPARTMENT OF HEALTH f - - i
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
ft
n{ Carol Lee Corlew Male
ft Date of Death Age If Veteran of U.S. Armed Forces,
May 21,2017 70 War or Dates
�'o` Place of Death • Hospital, Institution or
It City, Town or Village Glens Falls Street Address 1 South Delaware Ave,Apt. 106
IIManner of Death X Natural Cause I J Accident ❑Homicide Suicide n Undetermined • Pending
Circumstances Investigation
Medical Certifier Name Title
Joseph C.Minhindu Dr.
01 Address
M 20 Murray Street,Glens Falls,NY 12801i�
0Death Certificate Filed District Number Register Number
in City, Town or Village Glens Falls 5601
❑Burial Date Cemetery or Crematory
May 23,2017 Pine View Crematorium
❑Entombment Address
L1 Cremation 51 Quaker Road, Queensbury, NY 12804
Date Place Removed
ZO ❑Removal and/or Held
and/or Address
H Hold
Cl)
O Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
ffl Name of Funeral Home Regan Denny Stafford Funeral Home 01443
I Address
53 Quaker Road, Queensbury,NY 12804
fry'> Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
It
Permission is hereby granted to dispose of the human remains described above as indicated.
0 Date Issued 51 Zy 1 7 Registrar of Vital Statistics /UC� Ar
sir;: (signatu�)
sr<
iig District Number 5601 Place Glens Falls ?y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition siZ5 Jf1 Place of Disposition gyill-s-01 C,,,rnct{v
W (address)
CA
0 (section) 4"(lot number) (grave number)
QName of Sexton or Person in Charge of Premises /1f,; r J�a►,tit
�Z a (plcse print)
Signature L-L /�� Title CRiMIV011
(over)
DOH-1555(02/2004)