Spellacy, Julie NEW YORK STATE DEPARTMENT OF HEALTH '' it 7/i
Vital Records Section Burial - Transit Permit
51, Name First Middle Last Sex
Julie Ann Spellacy Female
Date of Death Age If Veteran of U.S. Armed Forces,
3 ,, September 28, 2018 59 War or Dates
Place of Death Hospital, Institution or
W`
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death❑Natural Cause ❑ Accident LiHomicide ❑ Suicide ❑ Undetermined ri❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
C Robert Evans,
Address
One Irongate Center Glens Falls, NY 12801
Death Certificate Filed District NumbL;,y _` Register Number
City, Town or Village 1-u
r`' ❑Burial Date Cemetery or Crematory
❑Entombment Address
❑Cremation
Date Place Removed
'° Removal
and/or and/or Held
Hold Address
fib Date Point of
'0 Transportation Shipment
by Common Destination
Carrier
0 Disinterment Date Cemetery Address
6 ❑ Reinterment Date Cemetery Address
00
44 Permit Issued to Registration Number
'., Name of Funeral Home Carleton Funeral Home, Inc. 00281
4„304 Address
004
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
y Remains are Shipped, If Other than Above
Address
:a
,, Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10 I-2-12Zlcc Registrar of Vital Statistics �� �' t,0- Adir- -"
(signature)
District Number (gyp I Place 6 u-A"s Feik `1 Sl LI
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
a Date of Disposition 1 /3 I ig Place of Disposition i L., iri di',
Zi:- (address)
U'
(section) (loumber,) � (grave number)
Z
Name of Sexton or Person in Charge of Premises ( r'� L' 14Aitt
(please rint)
Signature IY 4 Title I/ t1142
(over)
DOH-1555 (02/2004)