Abbey, Ann NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Ann Exilda Abbey Female
Date of Death Age If Veteran of U.S. Armed Forces,
April 16, 2014 81 War or Dates
I Place of Death Hospital, Institution or
W' Rc• Ior Village Granville Street Address INDIAN RIVER REHAB & HLTH CARE
CI Manner of Death(LiNatural Cause Accident � Homicide Suicide � Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
mhnmas Kandora, MD
Address
1 Indian River Rehab & Healthcare, Granville, NY
Death Certificate Filed District Number Register mber
eftisztaxed.Village Granvi l le _S7?T,5—
®Burial Date Cemetery or Crematory
April 19, 2014 Pine View Cemetery
!❑Entombment Address
❑Cremation Quaker Rd. Queensbury,NY 12804
Date Place Removed
zriRemoval and/or Held
and/or Address
p Hold Pine View Cemetery
to Date Point of
n Transportation
0. I 1 Shipment
U? by Common Destination
3 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
Address
w
Permission is he by ranted to dispose of the human rem. s dessri ed bo -- as indicated.
Date Issued Registrar of Vital Statistics jr/ " f _, //
(signature)
,,, District Number 57,.?5 Place 6raif, //L,Ai
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F^:
La Date of Disposition 04/19/2014 Place of Disposition Quaker Rd. Queensbury,NY 12804
(address)
W Seneca 17 B 2
t (section) (lot number) (grave number)
,04 Connie L. Goedert
0 Name of Se ton or Person in Charge of Premises
Z (please print)
LI•I' Signatur -j-e---a2z—,-- Title Superintendent
(over)
DOH-1555 (02/2004)