Cass, Ruth VNEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
ital Records Section
Name First Middle Last Sex
Ruth Mildred Cass Female
Date of Death Age If Veteran of U.S. Armed Forces,
February 19, 2012 88 War or Dates
Z Place of Death Hospital, Institution or
W City, Town or Village Queensbury Street Address 140 Robert Gardens
Manner of Deathm
I.Lu Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
0, Circumstances Investigation
111 Medical Certifier Name Title
ri Thomas Coppens, M.D. Dr.
Address
Three Irongate Center Glens Falls, NY 12801
Death Certificate Filed District Number Registeumber
City, Town or Village -"-":71Q '7 I
®Burial Date Cemetery or Crematory
February 21, 2012 Pine View Cemetery
• ❑Entombment
Address
OCremation Quaker Rd. Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
• and/or Address
E Hold Pine View Cemetery
0) Date Point of
a. ❑Transportation Shipment
• by Common Destination
• 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
' Name of Funeral Firm Making Disposition or to Whom
;F Remains are Shipped, If Other than Above
Address
IX
a. Permission is hereby granted to dispose of the human remain closer" ed abo, as " icated.
Date Issued a_ cpi l I._ Registrar of Vital Statistics 4 PI
(signature)
District Number cc°{-7 Place C „ /f--
• I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition 2/21 /201 glace of Disposition Pine View Cemetery
_2+, (address)
W Erie 15 A 2
CO
rt (section) (lot number) (grave number)
0
Name of Sexton or Person " harge of Premises Michael Geni er
0 (please print)
W Signature +^' Title Superintendent
(over)
DOH-1555 (02/2004)