McClellan, Olvie ,`
fi
NEW YORK STATE DEPARTMENT OF HEALTI# {1�
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Olive Mae McClellan Female
.f Date of Death Age If Veteran of U.S. Armed Forces,
.` 11/13/2018 93 Years War or Dates
4 Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
c Manner of Death® Natural Cause Accident 0 Homicide ❑Suicide ❑Undetermined Pending
Circumstances Investigation
w Medical Certifier Name Title
43 Dean Reali DO
Address
:' 100 Park St,Glens Falls,New York 12801
. Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 537
CI Burial Date Cemetery or Crematory
11/15/2018 Pine View Crematorium
[]Entombment Address
®Cremation Queensbury Town, New York
em s —
Date Place Removed
C) Removal and/or Held and/or Address —
Hold
0 Date Point of
i L. Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
` Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address
11 68 Main Stpo Box 67,Hudson Falls.New York 12839
3 Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
W
IX
Permission is hereby granted to dispose of the human remains described above as Indicated.
Date Issued 11/15/2018 Registrar of Vital Statistics Robert,A Curtis''EGscronicatf}Signed)
(signature)
District Number 5601 Place Glens Falls, New York
I;; I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition iti i I. itt Place of Disposition �,1Li `1..TcL,
.2 (address)
0
(section) (lot number) (grave number)
0Name of Sexton or Person in Charge of Premises (r; rpL tA.t r
Z (plellse print)
11 Signature Zi Title Ali'
(over)
DOH-1555 (02/2004)