Mingo, Mary II
NEW YORK STATE DEPARTMENT OF HEALTH �7
Vital Records Section Burial - Transit Permit
A Name First Middle Last Sex
Mary Jane Mingo Female
Date of Death Age If Veteran of U.S. Armed Forces,
01/04/2018 92 Years War or Dates
Place of Death Hospital, Institution or
ii. City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death®Natural Cause 0 Accident El Homicide El Suicide riUndetermined ri Pending
vs
Circumstances Investigation
W Medical Certifier Name Title
Marvin Davidowitz MD
Address
' 100 Park St,Glens Falls,New York 12801
4 Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 7
Burial Date — Cemetery or Crematory
01/08/2018 Pine View Crematorium
❑Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
Z Q Removal and/or Held
and/or Address
Hold
Date Point of
D Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Al
it �Reinterment
Date Cemetery Address
Permit Issued to Registration Number
i' 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
E Remains are Shipped, If Other than Above
Address
CC
Permission is hereby granted to dispose of the human remains described above as indicated.
e
Date Issued 01/08/2018 Registrar of Vital Statistics Robert A Curtis tECectronicafy Signed)
i (signature)
.` District Number 5601 Place Glens Fails, New York
t1I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 1 fl lig Place of Disposition 'CAP *^ r o ,
a' (address)
IIJYI''
CC (section) it(lot number( (grave number)
8 Name of Sexton or Person in Charge of Pre ises /4,4 -- J'"40
Z.
4 (pI ase print)
,, Signature
`"t ,,�%- Title N1
(over)
DOH-1555 (02/2004)