Kestner, Daphne NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
a Daphne C. Kestner Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 4, 2016 93 War or Dates
— Place of Death Hospital, Institution or
6:3i City, Town or Village Queensbury Street Address STANTON HEALTH & REHAB CTR.
ISA Manner of Death a Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
!' Medical Certifier Name Title
cr Bernardo R Villajuan MD,
Address
,- `- 161 Carey Road Queensbury, NY 12804
Death Certificate Filed District Number Register Number
,'.5 City, Town or Village 5l.r 51 3
' .®Burial Date Cemetery or Crematory
March 8, 2016
- ❑Entombment Address
'I❑Cremation
Pm L. Date Place Removed
v Removal and/or Held
d❑ and/or Address
:F== Hold
0:: Date Point of
.'� `❑Transportation Shipment
by Common Destination
�E Carrier
❑ Disinterment Date Cemetery Address
:;❑ Reinterment
Date Cemetery Address
• : Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
ILl:r, Address
_. .° Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
8'° Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
inHCCI
Permission is hereby granted to dispose of the human remai �dA�es'�cribed above as indicated.
'' Date Issued 'I I I,D.O l t, Registrar of Vital Statistics J - -SA.--p,-12a' -
(signature)
74*:-
A District Number 5 L9 S1 Place Q 0 c c f 1S bVICI
- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
wDate of Disposition 03/08/2016 Place of Disposition Pine View ('PmQi-pry, Quaench»ry, ivy
(address)
Oneida Lot 13 1
'ir (section) (lot number) (grave number)
aName of Sition or Person ' _ harge
- (please print)
Signatur 1 0:l1tL Title Cemetery Superintendent
(over)
DOH-1555 (02/2004)