DeLong, Helen NEW YORK STATE DEPARTMENT OF HEALTH
' Vital Records Section Burial - Transit Permit
I
Name First Middle Last Sex
Helen Marie DeLong Female
Date of Death Age If Veteran of U.S. Armed Forces,
October 21, 2011 81 War or Dates
1--; Place of Death Hospital, Institution or
W; City, Town or Village Queensbury Street Address The Stanton Nursing & Rehab. Center
Ill
Manner of Death a Natural Cause Ei Accident El Homicide El Suicide DUndetermined ri Pending
Circumstances Investigation
WW" Medical Certifier Name Title
Suzanne Blood,
Address
14 Mannor Drive, Queensbury, NY
DEP-rt4ate File D' t N tuber Regit+r Number
Ciwn or illageb O�..r-ti,� �p � 11
®Bursar Date Cemetery or Crematory
October 25, 2011 Pine View Cemetery
❑Entombment Address
❑Cremation Quaker Rd. Queensbury,NY 12804
Date Place Removed
Removal
0 and/or and/or Held
H Hold Address
Pine View Cemetery
0) Date Point of
a0 Transportation Shipment
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
F--; Remains are Shipped, If Other than Above
2 Address
IX
W;
IL Permission is hereby granted to dispose of the human m 'ns describe abo as indicated.
Date Issued '\O\ .t l`Registrar of Vital Statistics !Lk
-�-� C_ (signature)
�� ce -
District NumbE Pla1 _ 0 '
I certify that the remains of the decedent identified above were disposed of in accordance ' this permit on:
w Date of Disposition 1 0/25/11 Place of Disposition Pine View Cemetery
W (address)
Mohawk 79 3
d (section) (lot number) (grave number)
C] Name of Sexton or Pers n 'n Charge of Premises Michael Genier
W _ (please print)
Signature Title Superinetendent
(over)
DOH-1555 (02/2004)