Andrus, Barbara NEON Ycti^.K STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Barbara L. Andrus Female
Date of Death Age If Veteran of U.S. Armed Forces,
July 19, 2012 54 War or Dates
F-' Place of Death Hospital, Institution or
i
w Cty, Town or Village Glens Falls Street Address Glens Falls Hospital
W
Manner of Death� Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
CI Mark Hoffman MD,
Address
420 Glen St. Glens Falls, NY 12801
Death Certificate Filed District Number C Register Number
City, Town or Village - 6 0 ) J fj
Burial Date Cemetery or Crematory
July 24, 2012 Pine View Cemetery
❑Entombment Address
OCremation Quaker Rd. Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
1-- Hold Pine View Cemetery
0- Date Point of
d ❑Transportation Shipment
(I by Common Destination
C1 Carrier
Date Cemetery Address
ill Disinterment
�U 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
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date !ssued-11'2_3 ))2. Registrar of Vital Statistics w CMS?-.., l_lJ-1\-^
(signature)
District Number 560 j Place 6 l' rS Fcx, \l S / N li
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition 7/2 4/1 2 Place of Disposition Pine View Cemetery
2 (address)
Mohawk 74 3
(section) (lot number) (grave number)
pName of Sexton or Person in harge of Premises Michael Genier
(please print)
WSignature \ Title Superintendent
(over)
DOH-1555 (02/2004)