Weinberg, Adelaide NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Adelaide A. Weinberg Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 11, 2013 86 War or Dates
14 P e of Death Hospital, Institution or
W own or Village Glens Falls Street Address The Pines
W' ner of Death 0 Natural Cause 0 Accident Homicide Suicide D Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
CI Maureen Hyland - FNP,
Address
170 Warren Street Glens Falls, NY 12801
D th Certificate Filed District Number • Register fJ,uj ber
ity„)Town or Village 0/MS,r4'//S NY ��®/ Q.j
Burial Date Cemetery or Crematory
MrLtG�, 1 L> Pine View Cemetery
❑Entombment Address
❑Cremation Quaker Rd. Queensbury,NY 12804
Date Place Removed
Removal and/or Held
and/or Address
F- Hold Pine View Cemetery
0 Date Point of
ci. Li Transportation Shipment
CO by Common Destination
CI Carrier
Disinterment Date Cemetery Address
ElReinterment 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
I— Remains are Shipped, If Other than Above
2 Address
Ct
0' Permission is hereby granted to dispose of the human remains d�b�a e a i cated.
3 iL3 Registrar of Vital Statistics
Date Issued ��� (signature)
District Number S6a/ Place ael2S/1or//5 il /0?c/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
i�j,i Date of Disposition 3/1 4/1 3 Place of Disposition Pine View Cemetery
(address)
CO Horicon 1 H 2
re (section) (lot number) (grave number)
0
Name of Sexton or P on in Charge of Premises Ronald Montesi
(please print)
11.1 �.. �.�z2 Title
,-
(over)
DOH-1555 (02/2004)