Riley, Crystal t - ) 4L/b
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Crystal Lynn Riley Female
4 1-4 Date of Death Age If Veteran of U.S. Armed Forces,
August 12, 2017 33 War or Dates
1 la e of Death Hospital, Institution or
W City Town or Village Glens Falls Street Address 148 South Street
nner of Death Natural Cause � Accident ® Homicide Suicide Undetermined Pending
Circumstances Investigation
l Medical Certifier Name Title
Michael Sikirica MD,
Address
50 Broad Street Waterford, NY 12188
!r-- h Certificate Filed District Number Register Number
Town or Village 6( i. r S ceCit. (c 5601 t--I 30
1■ Burial Date Cemetery or Crematory
August 15, 2017 Pine View Crematorium
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
-k' Date Place Removed
Z,❑ Removal and/or Held
• and/or Address
i_ Hold
CO Date Point of
il ❑Transportation Shipment
(I) by Common Destination
171 Carrier
Or
Disinterment Date Cemetery Address
Date Cemetery Address
Ei Reinterment
. 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
Address
r C
• Permission is hereb gr nnted to dispose of the human remains des ibb d b as . ated.
• Date Issued 0 F �f/ /2 Registrar of Vital Statistics �� �
(signature)
(
District Number 5601 Place /' _`ts /t Y
i , I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
.- Date of Disposition 08/15/2017 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
It (section) (lot number) (grave number)
a. Name of Sexton or Person in Charge of Premises t Stiltll
z ( ease print)
W Signature a 4 Title l he(�(.,
(over)
DOH-1555 (02/2004)