Stockman, Edith NEW YORKSTATE DEPARTMENT OF HEALTH
Vital Recor :,Section Burial - Transit Permit
Name First Middle Last Sex
Edith Elizabeth Stockman Female
Date of Death Age If Veteran of U.S. Armed Forces,
February 19, 2014 93 War or Dates
� Place of Death Hospital, Institution or
W°
. City, Town or Village Glens Falls Street Address Glens Falls Hospital
0 Manner of Death 0 Natural Cause 0 Accident 0 Homicide n Suicide nUndetermined 0 Pending
WCircumstances Investigation
W Medical Certifier Name Title
W,
James North, M.D
Address
100 Broad St. Glens Falls, NY 12801
Death Certificate Filed District Number Register Number r
City, Town or Village 5601
®Burial Date Cemetery or Crematory
February 24, 2014 Pine View Cemetery
40 0 Entombment Address
['Cremation Quaker Rd. Queensbury,NY 12804
Date Place Removed
0.Ell
Removal and/or and/or Held
Address
E Hold Pine View Cemetery
(7) Date Point of
Chi, 0 Transportation Shipment
0 by Common Destination
a Carrier
Disinterment Date Cemetery Address
0 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
f=, Remains are Shipped, If Other than Above
Address
tc
W
Permission is hereby granted to dispose of the human remains describ b e di
Date Issued 0 2o�0/ye Registrar of Vital Statistics .
(signature)
District Number 5601 Place a 5, /J/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
ui' Date of Disposition 02/24/2014 Place of Disposition Quaker Rd. Queensbury,NY 12804
2 (address)
W, Wah Ta Wah Sec. 34 382 5
0)
pe (section) (lot number) (grave number)
9 Name of Se„en or Person in Charge of Premises Connie L. Goedert
W Signature,
r 1 il Title Superintendent( t
(over)
DOH-1555 (02/2004)