Strout, Julia r"�7.-/
NEW YORK STATE DEPARTMENT OF HEALl'H 1 =
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Julia Frances Strout Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 13, 2017 72 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Street Address 179 South St, Apt. 1
wManner of Death a Natural Cause Accident Homicide Suicide � Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
James North, M.D
Address
100 Broad St. Glens Falls, NY 12801
Death Certificate Filed District Number ' Register Number 1(0 q
City, Town or Village
0 Burial Date Cemetery or Crematory
March 21, 2017 Pine View Crematorium
_, ❑Entombment Address
-0 Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
and/or Removal and/or Held
Hold Address
C� Date Point of
0:;❑Transportation Shipment
Q) 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
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
• Address
IX
W
11` Permission is hereby granted to dispose of the human remains described bov a incl. e .
Registrar of Vitat Statistics
Date Issued D3�/7�Z�Y 7 /'�' 6� dQ-z.
signature)
District Number J-669/ Place (;% /f
I certify that the remains off�the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 03/�+F12017 Place of Disposition Quaker Road Queensbury,NY 12804 r 2 ;e,w
2 (address)
w
co
ce (section) x (lot umber) // (grave number)
• Name of Sexton or P so i Charge of Premises �� ✓t G cal Gait
Z (please print)
41 Signature Title femme 1-0
(over)
DOH-1555(02/2004)