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Drew, Darlene NEW YORK STATE DEPARTMENT OF HEALTH ( 17-r Vital Records Section Burial - Transit Permit Name First Middle Last Sex 1 Darlene Ann Drew Female Date of Death Age If Veteran of U.S. Armed Forces, December 6, 2017 59 War or Dates Place of Death Hospital, Institution or.. City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death 0 Natural Cause 0 Accident ❑ Homicide ❑ Suicide ❑ Undetermined 11 Pending Circumstances Investigation W. 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 S , / ❑Burial Date Cemetery or Crematory December 11, 2017 Pine View Crematorium ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 ` Date Place Removed rtElRemoval and/or Held and/or Address Hold Pine View Crematorium Date Point of Transportation Shipment '40i by Common Destination 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 rLe Remains are Shipped, If Other than Above Address M is Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued J 2.1 f 1/ i7 Registrar of Vital Statistics Ck7C y,-.ie,a(-,0,,^ (signature) District Number 5'60 l Place ELP--v‘S i\s L)y R4 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 12/11/2017 Place of Disposition Quaker Road Queensbury,NY 12804 2: (address) ' 1,1 "ix; (section) (lot number) e., (grave number) 0, Name of Sexton or Person in Charge of P mises (r.s''i}}''V- Ja,Ap" Z 4 (please print) l,, Signature Title (F 1'10\VA (over) DOH-1555 (02/2004)