Simonetta, Hilda NEWORK STATE DEPARTMENT OF HEALTH
Burial - Transit Permit
Vital Records Section
..° Name First Middle Last Sex
Hilda Marie Simonetta Female
Date of Death Age If Veteran of U.S. Armed Forces,
{ March 17, 2014 101 War or Dates
� Place of Death Hospital, Institution or
il.l' City, Town or Village Fort Edward Street Address FORT HUDSON HEALTH CARE FAC.
WManner of Death Natural Cause 0 Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
Bernardo R Villajuan MD, i
Address
161 Carey Road Queensbury, NY 12804
tel: Death Certificate Filed District Number ,6 Regis r umber
j City, Town or Village
®Burial Date Cemetery or Crematory
March 22, 2014 Pine View Cemetery
❑Entombment Address
['Cremation Quaker Rd. Queensbury,NY 12804
Date Place Removed
Removal and/or Held
Hold and/or Address
Pine View Cemetery
10 Date Point of
Transportation Shipment
by Common Destination
'cl 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
s; Name of Funeral Firm Making Disposition or to Whom
b Remains are Shipped, If Other than Above
Address
M
in,
a.
Permission is ere y granted to dispose of the human e ins described ab ve a indicated.
Date Issued Registrar of Vital Statistics /�
(signature
District Number 6"� Place C3� �,( ILC
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 03/22/2014 Place of Disposition Quaker Rd. Queensbury,NY 12804
(address)
Ili 6 grave lot, Hudson Sec. 2 1 5A 5
co
hys4 they e (lot number) (grave number)
Name of Sexton or Person in Charge of Premises Connie L. Goedert
71
Z C (please print)
Signatures Title Superintendent
(over)
DOH-1555(02/2004)