Harrington, Grace NEW"ORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Grace Mae Harrington Female
Date of Death Age If Veteran of U.S. Armed Forces,
April 17, 2013 85 War or Dates
F- Place of Death Hospital, Institution or
W i Town or Village Glens Falls Street Address Glens Falls Hospital
a Manner of Death Natural Cause III Accident 0 Homicide ❑ Suicide Undetermined ri❑ Pending
ILIJ Circumstances Investigation
J Medical Certifier Name Title
'C Sean Bain, M.D. Dr.
Address
100 park St. Glens Falls, NY 12801
Death Certificate Filed District Number u y; Register Number
pTown or Village C let I(J 5601 brial
Date Cemetery or Crematory
April 20, 2013
❑Entombment Address
❑Cremation
Date Place Removed
z ri Removal and/or Held
and/or Address
Hold
i`' Date Point of
a ❑Transportation Shipment
(1) by Common Destination
O 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
1-- Remains are Shipped, If Other than Above
2 Address
IX
1.t1''
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued y / i q //.3 Registrar of Vital Statistics WCA.�../ q L,Q
(signature)
District Number 5601 Place geogs falls /tAi/v2 7t
h- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 4/20/1 3 Place of Disposition Pine View Cemetery
M (address)
LU Hudson Sec. 3 5 2
re (section) (lot number) (grave number)
0 inName of Se ton or Person in Charge of Premises Connie L. Goedert
lee print)
W Signature, � i' Title Superintendent
(over)
DOH-1555 (02/2004)