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White, Marcia G4EW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Marcia Ann White Female Date of Death Age If Veteran of U.S. Armed Forces, September 4, 2013 69 War or Dates Place of Death Hospital, Institution or W; City, Town or Village Queensbury Street Address The Stanton Nursing & Rehab. Center E3 Manner of Death 0 Natural Cause ❑ Accident ❑Homicide El Suicide n Undetermined ❑ Pending WCircumstances Investigation W' Medical Certifier Name Title W Roslyn Socolof_MD, Address 100 Broad St Plaza Glens Falls, NY 12801 Deicate Filed Di ct Number R gist r Number Ci y, Town of Village �p _ (.9ElBuna Date Cemetery or Crematory September 9, 2013 Pine View Cemetery ❑Entombment Address ❑Cremation Quaker Rd. Queensbury,NY 12804 Date I Place Removed z ❑ Removal I and/or Held and/or Address E Hold View Ce CO Date Point of , I I Transportation Shipment CO;, by Common Destination £ Carrier Date Cemetery Address Ell Disinterment Date Cemetery Address ❑ Reinterment 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—I Remains are Shipped, If Other than Above 2` Address W 0- Permission is hereby granted to dispose of the human r ns describ�d above indicated. Date Issued ) (� I&Ok Registrar of Vital Statistics --___ ej (signature) District Number c'(.._ c—1 Place )(-)L,--,r^Z oC ,o -1P1Sk-v —, I certify that the remains of the decedent identified above were disposed of in accord- ce wi this permit on: W Date of Disposition 9/9/1 3 Place of Disposition Pine View Cemetery 2' (address) LliCO' Hudson Sec. 3 268 4 ce (section) (lot number) (grave number) 0 Name of Se or Person in Charge of Premises Connie L. Goedert © / (please print) W Signature �' t Title Superintendent / (over) DOH-1555 (02/2004)