Irish, Elizabeth NEW YORikSTATE DEPARTMENT OF HEALTH
Vital'kecords Section Burial - Transit Permit
Name First Middle Last Sex
Elizabeth Ann Irish Female
Date of Death Age If Veteran of U.S. Armed Forces,
September 22, 2014 79 War or Dates
F-, Place of Death Hospital, Institution or
W City, Town or Village Queensbury Street Address The Stanton Nursing & Rehab. Center
W Manner of Death X❑ Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ri 1--I Pending
0 CircumstancesInvestigation
W Medical Certifier Name Title
a.' Bernardo R Villajuan MD,
Address
161 Carey Road Queensbury, NY 12804
Death Certificate Filed District Number R 9irtNumber
_ City, Town or Village 5657
®Burial Date Cemetery or Crematory
September 29, 2014 Pine View Cemetery
0 Entombment Address
❑Cremation Quaker Rd. Queensbury,NY 12804
Date Place Removed
z ri Removal and/or Held
• and/or Address
H Hold Pine View Cemetery
0 Date Point of
❑Transportation Shipment
0 by Common Destination
5 Carrier
111 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
f=i. Remains are Shipped, If Other than Above
2 Address
CC
11 Permission is hereby granted to dispose of the human re \nss described/ 7ov,� as indicated.
Date Issue L D,Lt 10(3 Registrar of Vital Statistics J"`—� Q / `� --_„.
/�
(signature)
District Number 5657 Place (.�-� C� CD
fi disposed of in acance with this permit on:d above were
I certify that the remains of the decedent identified
w
W Date of Disposition 09/29/2014 Place of Disposition Quaker Rd. Queensbury,NY 12804
2 (address)
W New 2 Grave 59 A Erie
CO L?Section) (lot number) (grave number)
Connie L. Goedert
O• Name of S on or Person in Charge of Premises
Su eil�ift�rntaent
al Signature i •s, Title P
(over)
DOH-1555 (02/2004)