Hart, Charlotte NNEVI;YORK STATE DEPARTMENT OF HEALTH
t Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Charlotte Katherine Hart Female
Date of Death Age If Veteran of U.S. Armed Forces,
April 26, 2016 87 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address 450 Lower Main St.
I`�
Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide 0 Undetermined 17❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Eileen S•inelli, NP
Address
9 Carey Rd Queensbury, NY 12804
Death Certificate Filed District Number J "�r) 55 RTgi ter Number
City, Town or Village
®Burial Date Cemetery or Crematory
April 29, 2016 Pine View Cemetery
❑Entombment Address
❑Cremation Quaker Rd. Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold Pine View Cemetery
r Date Point of
Transportation Shipment
by Common Destination
Carrier
0 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
Remains are Shipped, If Other than Above
Address
gr
Permission is ereby granted to dispose of the huma r 'ns d scri ed a o a indicated.
Date Issued 'per-1(o Registrar of Vital Statistics V t
(sig ature)
District NumbeL6'),5 Place ��� y�6 ��
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
aDate of Disposition 04/29/2016 Place of Disposition Quaker Rd. Queensbury,NY 12804
(address)
2
(section)Mohawk (lot number) (grave number)
Name of Sexto or Person in Charge of Pre ' s Connie L. Goedert
(please print)
Signature 4. c '::e Title Cemetery Superintendent
(over)
DOH-1555 (02/2004)