Briere, Mary NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Mary Theresa Briere Female
Date of Death Age If Veteran of U.S. Armed Forces,
June 1, 2012 76 War or Dates
Place of Death Hospital, Institution or
w City, Town or Village Glens Falls Street Address Glens Falls Hospital
Cli Manner of Death 0 Natural Cause Accident ❑Homicide ❑ Suicide ❑ Undetermined Pending
CI Circumstances Investigation
W Medical Certifier Name Title
t3'. Danushan Sooribalan, M.D
Address
102 Park Street Glens Falls, NY 12801
Death Certificate Filed I� District Number Register Number
City, Town or Village L` <<iJ J 5601 21,e
®Burial Date (p Cemetery or Crematory
June S, 2012 ST. ALPHONSUS CEMETERY
❑Entombment Address
El Cremation Town of Queensbury,NY
Date Place Removed
z ❑ Removal and/or Held
0 and/or Address
p Hold ST. ALPHONSUS CEMETERY
0 Date Point of
0'❑ Transportation Shipment
0 by Common Destination
11 Carrier
z El 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
2 Address
W.
"" Permission is hereby granted to dispose of the human remains described above aq indicated.
Date Issued 6/ y / 1 Z, Registrar of Vital Statistics UJ CA., .. VW w.c -ar
(signature)
District Number 5601 Place 6 1 5 \ s N
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H
WDate of Disposition Place of Disposition
',� UAt� (address)
co
re (section) (lot number) (grave number)
aName of Sexton or Person in Charge of Premises
please print)
Ill Signature Title
(over)
DOH-1555 (02/2004)