Richards, Grace NEW YORK STATE DEPARTMENT OF HEALTH 3 I I'�
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
,` Grace J. Richards Female
Date of Death Age If Veteran of U.S. Armed Forces,
s.,1 June 5, 2017 90 War or Dates
I Place of Death Hospital, Institution or
wE, City, Town or Village Saratoga Springs Street Address WESLEY HEALTH CARE CENTER, INC
W0 Manner of Death El Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
0
W Medical Certifier Name Title
Ly Diane Westbrook NP,
Address
D h Certificate Filed District Number Register Number
#' i own or Village >pci1 ca. 59,j x,,3 L. ;St-DI 7-)li
Burial Date Cemetery or Crematory
June 7, 2017 Pine View Crematorium
❑Entombment Address
lik M Cremation Quaker Road Queensbury,NY 1.1 Date ' Place Removed
❑ Removal I and/or Held
and/or Address
Hold Pine View Cemetery
0 Date Point of
,❑Transportation Shipment
V: by Common Destination
Carrier
❑ Disinterment
Date Cemetery Address
�F3
❑ Reinterment Date Cemetery Address
€
E 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
Y Name of Funeral Firm Making Disposition or to Whom
F-= Remains are Shipped, If Other than Above
Address
: Permission is h eb granted to dispose of the human rema' cri d ab..%ce indicate .
$ ? Date Issued Registrar of Vital Statistics
(signature)
ri District Number LA 501 PlaceSA--)2JpelOC...4- -P (A)(l1 5
-33
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
_Ili Date of Disposition 06/07/2017 Place of Disposition Quaker Road Queensbury,NY 12804
s (address)
r (section) lot number) (grave number)
°; Name of Sexton or Person in Charge of P emises ar Twirl
3z (pl se print)
Signature li'"` 1 Title AIM-
(over)
DOH-1555 (02/2004)