Zeno, Carmela NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Carmel C Zeno Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 30, 2013 100 War or Dates
f,,., Place of Death Hospital, Institution or
ZCity, Town or Village Ft. Edward Street Address Fort Hudson Nursing Home
' Manner of Death Undetermined Pending
i �Natural Cause Accident �Homicide �Suicide
1, Circumstances Investigation
Medical Certifier Name Title
Charlene Harrington,MD
Address
327 Broadway Fort Edward,NY
Death Certificate Filed Distric Number Regist lr Number
City, Town or Village Ft Edward 75 67
❑Burial Date Cemetery or Crematory
April 2, 2013 Pine View Creamtory
❑Entombment Address
❑x Cremation Quaker Road, Queeensbury, NY
Date Place Removed
ZZ n Removal and/or Held
and/or Address
H Hold
0 Date Point of
5 n Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
{., 53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped, If Other than Above
Address
ILI
aPermission is eb granted to dispose of the human r ains described above s indicated.
Date Issued Registrar of Vital Statistic
(signature)
District Number 6.--2z, Place Ft Edward
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z r1
W Date of Disposition 4 -
-3-13 Place of Disposition 204.04t4 C'tirrctr'ih-'
2 (address)
W
O (section) XL- lot number) e— (grave number)O Name of Sexton or Person in Charge of P emises JPl
Z
(please print)
W 7414..... Title reerl et i
Signature
(over)
DOH-1555(02/2004)