Carr, Eileen NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
•t"` Eileen C. Carr Female
eo
X Date of Death Age If Veteran of U.S. Armed Forces,
-- February 12, 2014 93 War or Dates
0' Place of Death Hospital, Institution or
Z.«. City, Town or Village Granville, NY Street Address Orchard Nursing& Rehab Center
Manner of Death X Natural Cause Accident ❑Homicide ❑Suicide n Undetermined Pending
Circumstances Investigation
Medical Certifief Name Title
MD
m c)._ , Address
1 \C\1/4•6-
z`R? Death Certificate Filed District Number Register Number
City, Town or Village Granville,NY .5756 I
®Burial Date Cemetery or Crematory
February 18, 2014 Pine View Cemetery
El Entombment Address
E Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
ZO U Removal and/or Held
and/or Address
H Hold
N
O Date Point of
W ❑Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
Ei 407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
E
W Permission is hereby granted to dispose of the human remains described above as indicated.
f f Date Issued oa/I 31e).6 14 Registrar of Vital Statistics "L q 6
(sig ature)
< District Number 5-7Sh Place Granville,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 2/1 8/1 4 Place of Disposition Pine View Cemetery
2 (address)
W
N Mohican 69 A 2
W (section) (lot number) (grave number)
Q Name of Sexton or Person in Charge of Premises Connie L. Goedert
Z (please print)ILI
Signature J t ,.e66.4, Title Superintendent
(over)
DOH-1555(02/2004)