Critchley, Donna NEW YORK STATE DEPARTMENT OF HEALTH) 1
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Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Donna Marie Critchley Female
;` Date of Death Age If Veteran of U.S. Armed Forces,
January 27, 2018 63 War or Dates
Place eath Hospital, Institution or
City, owpj or Village Ina f z a-`A-- Street Address 116 Bluebird Terrace, Lot 31
ILIManner of Death nj Natural Cause 0 Accident 0 Homicide 0 Suicide IDUpdetermined El Pending
Lti Circumstances Investigation
W Medical Certifier Name Title
9''; David T. Slingerland, Dr.
Address
Broad Street Health Center Glens Falls, NY 12801
Death -II ificate Filed Distri t b� Registermber
fr, Ci Town •r Village m o r ea- t'`-
0 Burial Date Cemetery or Crematory
4i:go February 1, 2018 Pine View Crematorium
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
Removal and/or Held
and/or Address
p Hold
{t): Date Point of
` Transportation _ Shipment
by Common Destination
p Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
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
I- " Remains are Shipped, If Other than Above
I
Address __
w
E1• Permission is hereby granted to dispose of the human remai escribed . .,v 1=s indicated.
Date Issued Registrar of Vital Statistics_ /&WY.(
/ ( (signal re) , /
`vo• -
District Number �, / �e IIC) CIS l�' GNU `w/ d�o��� Place J � � �
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 02/01/2018 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
i'-
0)4
(section) //4?L-
(lot number) (grave number)
Name of Sexton or Person in Charge of Pre ises1S -
z
lease print)
ill, Signature Title ft-P
(over)
DOH-1555 (02/2004)