Underwood, Mary NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
PT Name First Middle Last Sex
vs Mary Lucille Underwood Female
Date of Death Age If Veteran of U.S. Armed Forces,
x^,'= 02/09/2018 89 Years War or Dates
fi:.; Place of Death Hospital, Institution or
City, Town or Village Guilderland Town Street Address The Grand at Guiiderland
et Manner of Death In Natural Cause 0 Accident 1=IHomicide 0 Suicide Undetermined El Pending
Circumstances Investigation
�, Medical Certifier Name Title
o Lynn Fabre NP
Address
i 127 Main St,Guiideriand Town,New York 12085
Death Certificate Filed District Number Register Number
City, Town or Village Guiiderland 0155 25
` ❑Burial Date Cemetery or Crematory
02/14/2018 Pine View Crematorium •
0 Entombment Address
4 ®Cremation Queensbury Town, New York
Date Place Removed
Z' Removal and/or Held
1 and/or Address
Hold
Date Point of
en El Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Date Cemetery Address
Reinterment
it Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
g Address
t ` 68 Main Stpo Box 67,Hudson Fails,New York 12839
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
LIA
f Permission Is hereby granted to dispose of the human remains described above as indicated.
a
Date Issued oz13/2018 Registrar of Vital Statistics Jean Jarrett Cataido(ECectranri;4i)Signed
(signature)
District Number 0155 Place Guiideriand, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
le Date of Disposition /l�/Lc i i Place of Disposition Pint, Vi f'�W Gcq eiod c r y
W (addr'ess)
1 (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises r t�Y 3
J .'f 2,u;f t 5
` (please print)
Signatur e//� e ,'"'/ Title Gf�,►^+��;ear
(over)
DOH-1555 (02/2004)