Osborne, Carmelina NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Carmelina M. Osborne Female
Date of Death Age If Veteran of U.S.Armed Forces,
August 6,2013 80 War or Dates
Place of Death Hospital, Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause Accident Homicide []Suicide Undetermined ri Pending
Circumstances Investigation
Q Medical Certifier Name Title
Scott Biasetti
Address
100 Park St,Glens Falls,NY 12801
Death Certificate Filed Glens Falls District Number Registelyu 1ber
City,Town or Village 5601
®gum Date Cemetery or Crematory
August 10,2013 Pine View Cemetery
Address
❑Cremation Quaker Road, Queensbury,,NY 12804
Date Place Removed
z El Removal and/or Held
and/or Address
H Hold
to
0 Date Point of
Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road,Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
2 Address
iu
0. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued it(g/1 3 Registrar of Vital Statistics CA) \_A)
(signature)
District Number 3601 Place Glens Falls,/v
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition 8/1 0/1 3 Place of Disposition Pine View Cemetery
2 (address)
N 6 D Abenaki 1
(seen) (lot number) (grave number)
p Name of Sexton or Person in Charge of Premises Connie L. Goedert
W Signature ,J CU4t9 Title 6_444.1u.,/
(over)
DOH-1555(02/2004)