James, Kathryn ! NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Kathryn James Female
Date of Death Age If Veteran of U.S. Armed Forces,
' January 14, 2017 44 War or Dates
Place ath Hospital, Institution or
d City, ow or Village Queensbury Street Address 25 Woodland Path
Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide Undetermined El❑ Pending
Circumstances Investigation
-: Medical Certifier Name Title
13= Michael Sikirica MD,
Address
50 Broad Street Waterford, NY 12188
y ' Death ificate Filed --a, tricINumber Re r Number
City Tow or Village t i-e e r)S U IA"1 S' )
I1 Burial Date Cemetery or Crematory •
T January 21, 2017 Pine View Cemetery
❑Entombment Address
El Cremation Quaker Rd. Queensbury,NY 12804
Date Place Removed
Removal1.0 and/or and/or Held
Hold Address
F_` Pine View Cemetery
0: Date Point of
''❑Transportation Shipment
Ai by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
G Reinterment Date Cemetery Address
Permit Issued to Registration Number
:4 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
_a. Name Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereb granted to dispose of the human re s described a qv as indicated.
Date Issued ( ( Registrar of Vital Statistics j C� Cl. (
(signature)
3-4District Numbers( ,S fl Place ) U t J d Q L . J2 I-dL
certify that the remains of the decedent identified above were disposed of in acc rdance ith this permit on:
Date of Disposition 01/21/2017 Place of Disposition Quaker Rd. Queensbury,NY 12804
2'. (address)
Ill
Erie 37B 2
' (section) (lot number) (grave number)
Name of Sex n or Person in Charge of Premises Connie L. Goedert
Zi * (please print)
IL, Signature i i Q. it 0 kg t Title Cemetery s»PPriv tpnrient
(over)
DOH-1555 (02/2004)