Vitouski, Joan NEW YORK STATE DEPARTMENT OF HEALTH i1 Z
Vital Records Section Burial - Transit Permit
Name First Middleex
�E;, Last S_
Joan Elizabeth Vitouski Female
Date of Death Age If Veteran of U.S. Armed Forces,
February 16, 2018 81 War or Dates
2.1 Place of Death Hospital, Institution or
City, Town or Village Hudson Falls Street Address 5 1/2 Ferris Street
14
Manner of DeathLiu Natural Cause 0 Accident ❑ Homicide ❑ Suicide 0 Undetermined ❑ Pending
Circumstances Investigation
LI Medical Certifier Name Titleta 5• Address
4 „ Death Certificate Filed District Number Register Number
: City, Town or Village .3 7..1-6 03
nh.❑Burial Date Cemetery or Crematory
February 21, 2018 Pine View Crematorium
x:❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
- , Hold
Date Point of
,;. ❑Transportation Shipment
by Common Destination
,Yks`. Carrier
''3, ❑ Disinterment Date Cemetery Address
Date CemeteryAddress
- ❑ Reinterment
'1,1 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
bp Remains are Shipped, If Other than Above
, , Address
,g Permission is hereby granted to dispose of the human rem 'ns described above as indicated.
Date Issued lot-ov-ac6e Registrar of Vital Statistics ' CQx›-.�� -
(signature)
*` District Numberg-7�,6 Place ' m-d--�-� Foes •
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F Date of Disposition 02/21/2018 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
W
,13,-=
(section) 4 (lot number) (grave number)
gName of Sexton or Person in Charge of Premises /XPA �4.-ii'
/f (p ase print)
Signature G� Title /PEAT'tn-
(over)
DOH-1555 (02/2004)