Waimon-Kaphan, Sybil NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Sybil Victoria Waimon-Kaphan Female
Date of Death Age If Veteran of U.S. Armed Forces,
August 26, 2015 91 War or Dates
I- Place of Death Hospital, Institution or
W City, Town or Village Queensbury Street Address 178 Aviation Road
CI Manner of Death Natural Cause ❑ Accident ❑ Homicide 0 Suicide ❑ Undetermined ❑ Pending
W Circumstances Investigation
U
W Medical Certifier Name Title
CI Robert Evans,
Address
One Irongate Center Glens Falls, NY 12801
Death Certificate Filed District Number Registerumber
City, Town or Village `j ci 5 (61.,
®Burial Date Cemetery or Crematory
August 28, 2015 Pine View Cemetery
❑Entombment Address
❑Cremation Quaker Rd. Queensbury,NY 12804
Date Place Removed
z IT
❑ Removal and/or Held
and/or Address
F Hold Pine View Cemetery
0) Date Point of
a. ❑Transportation Shipment
(I) by Common Destination
3 Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Reinterment
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
i— Remains are Shipped, If Other than Above
• Address
X
W
a. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued gig-1 jao!i Registrar of Vital Statistics . 1244-t.- ,,mot --
(signature)
District Number J(v 1 Place 0 V c cr1 c by/i
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
u Date of Disposition 08/28/2015 Place of Disposition Quaker Rd. Queensbury,NY 12804
2 (address)
W`
COHudson, Sec. 1 19B 1
Ce (section) (lot number) (grave number)
0 Name of Sexto or Person in Char e of Premises Connie L. Goedert
d
Z (please print)
al Signature �.0 Title Cemetery Superintendent
(over)
DOH-1555 (02/2004)