Weaver, Evelyn NEW YORK STATE DEPARTMENT C.� HEALTH Burial - Transit Permit
Vital Records Section
4 Name First Middle Last Sex
Evelyn Mae Weaver Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 8, 2011 94 War or Dates
r Place of Death Hospital, Institution or
City, Town or Village Hudson Falls Street Address 814 Dean Road
Manner of Death Natural Cause LI Accident El Homicide n Suicide ElUndetermined El Pending
Circumstances Investigation
�y M Medical Certifier Name Title
4n. Philip J Gara Jr. MD,
414 Address
4,1 327 Broadway Fort Edward, NY 12828
Death Certificate Filed District Nurni9er Register Number
City, Town or Village S a(a 0`-
J Burial Date Cemetery or Crematory
March 12, 2011 Pine View Cemetery
❑Entombment Address
DCremation Quaker Rd. Queensbury,NY 12804
Date Place Removed
ri Removal and/or Held
a- and/or
Hold Address
Pine View Cemetery
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
44,
`` Reinterment Date Cemetery Address
,; Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00276
Address
, Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
IT
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
, Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 3-Li (a 0 i/ Registrar of Vital Statistics .4„� t:�(20.-k-3-¢--(--
(signature)
District Number Place 1 ,--n J ',-.05
i
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 3/12/11 Place of Disposition Pine View Genet ery,
(address)
Hudson Sec. 1 9C 2
• (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises Michael Genier
,, (please print)
Signature 9 -f2/1-4-"' Title Superintendent
(over)
DOH-1555 (02/2004)