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Temple, Kristen Michele NEW YORK STATE DEPARTMENT OF HEALTH Burial- Transit Permit Bureau of Vital Records Name First Middle Last Sex Kristen Michele Temple I Female Date of Death Age If Veteran of U.S.Armed Forces, 04/25/2020 44 Years War or Dates Place of Death Hospital,Institution or WCity,Town or Village Fort Ann Town Street Address 1149 Brayton Road,Fort Ann Town,New York 12827 p Mannerof Death ©Natural Cause Accident ❑Homicide Suicide ❑Undetermined Pending W Circumstances Investigation WMedical Certifier Name Title Christopher Mason DO Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Fort Ann 5754 8 Burial Date Cemetery,Crematory or Facility Name El04/28/2020 Pine View Crematorium Entombment Address 0 Cremation Queensbury Town,New York ❑Donation ZO Removal Date Place Removed and/or and/or Held F-N Hold Address O 0- Date Point of N ❑Transportation Shipment p by Common Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67, Hudson Falls,New York 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 Issued 04/28/2020 Registrar of Vital Statistics Barbara Winchell(ECectronicalySigned} (signature/ District Number 5754 Place Fort Ann, New York I certify that the remains of the decedent identified above were di sed of in acc dance with this perm' on: F— W Date of Disposition -2 •?fJW Place of Disposition Iil4 Icy• 19�Rud LU (a dress) W N ( lon) (lot number) (grave number/ IIM / g Name of Sexton or Per i arg of Premises ut, zz- (please print/ W Signature Title DOH-1555(07/18)p 1 2 Public Health Law Sec. 4145(2b) 9 Receipt Human remains of i delivered on - , 20 i Pine View Cemetery ' Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#