Austin, VirginiaNEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Records
W-1 it b7l
Burial - Transit Permit
Middle Last
a Ann Austin Sex
Death Female
Age If Veteran of U.S. Armed Forces,
019 84 YeaWar or Dates
reFirst
f Death Hospital, Institution or
wn or Village Glens Falls Street Address Glens Falls Hospital
of Death Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Certifier Name
Title
Mathew Varughese DO
Address
100 Park St, Glens Falls, New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 407
Burial Date Cemetery, Crematory or Facility Name
Entombment 09/23/2019 Pine View Crematorium
Address
ZCremation
Queensbury Town, New York
Donation
zRemoval Date Place Removed
F— and/or and/or Held
Cl)
Hold
Address
d
1O
CO)
Transportation
Date
Point of
by Common
Shipment
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 Stpo Box 67, Hudson Falls, New York 12839
Name of Funeral Firm Making Disposition or to Whom
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 09/17/2019 Registrar of Vital Statistics �RgbertAndrew Curtis (ECectronicaCCy Signed)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
Date of Disposition 174 in Place of Disposition n„}o Ir,�..,
W
(address)
W
N
(section) (lot number (grave number)
0
Name of Sexton or Person in Charge of Premises
Z
lease print)
W
Signature Title /kAMA
DOH-1555 (o7/18) p 1 of 2
PUBLIC HEALTH LAW
§ 4145• Deaths; burial and removal permits; disposition of remains. 1. No person in charge of any premises on which
interments, cremations or other disposition of the body of a deceased person are made shall inter or permit the
interment or other disposition of any body unless it is accompanied by a burial, cremation or transit permit, as provided
in this article.
2. (a) The funeral director or undertaker shall deliver the burial permit to the person in charge of the place of burial or
other disposition before interring or otherwise disposing of the body or shall attach the removal or transit permit to the
box containing the body, when shipped by any transportation company, which permit shall accompany the remains to its
destination, where, if within this state, it shall be delivered to the person in charge of the place of burial or other
disposition.
(b) Any person or other entity owning, operating, managing, or designated to receive the body of a deceased person at a
place of burial, cremation, or other final disposition in this state, who receives the body of a deceased person, shall
provide a receipt for the body to the funeral director, undertaker or registered resident who delivered such body. Each
receipt shall (i) be endorsed by both such person and the funeral director, undertaker or registered resident, (ii) indicate
the date the body was delivered, (iii) include the name of the funeral director, undertaker or registered resident
delivering the body and the registration number of such funeral director, undertaker or registered resident, (iv) include
the name of the registered funeral firm the funeral director, undertaker or registered resident represents, (v) include the
name of the deceased person as it appears on the burial, cremation, or transit permit, and (vi),include the name of the
owner, operator, manager, or person in charge of the place of burial, cremation, or other final disposition who received
the body of the deceased person. A copy of such receipt shall be retained by the owner, operator, manager, or person in
charge of the place of burial, cremation, or other final disposition for a period of not less than four years, and shall be
made available for inspection by the division of cemeteries during normal business hours. The original copy of every such
receipt shall be retained by the licensed funeral firm for a period of not less than four years pursuant to the rules and
regulations of the department governing the maintenance of records.
3. The person in charge of the place of burial or other disposition shall endorse upon the permit, the date of interment,
or cremation or other disposition over his signature, and shall return all permits so endorsed to the registrar of his
district within seven days after the date of interment, cremation or other disposition.
4. When burying or otherwise disposing of the body of a deceased person in a cemetery or burial place having no
person in charge, the funeral director or undertaker shall (a) sign the burial or removal permit, giving the date of burial;
(b) write across the face of the permit the words "No person in charge; " and (c) file the burial or removal permit within
three days with the registrar of the district in which the cemetery is located.
5. The person in charge of the place of burial, cremation, or other disposition shall keep a record of all bodies interred or
otherwise disposed of on the premises under his charge, in each case stating the name of each deceased person, place of
death, date of burial or disposal, and name and address of the funeral director or undertaker, which record shall at all
time be open to official inspection.
DOH-1555 (07/18) p 2 of 2
Public Health Law Sec. 4145(2b)
012555
Receipt
Human remains of V, delivered on 6- I 20
Pine View Cemetery Representing the funeral home named,9n burial -nt
Official Funeral Directors Reg. or License #-