Reinersten, Charlotte NEW YORK STATE DEPARTMENT OF HEALTH t
Vital Records Section Burial - Transit Per it
,' Name First Middle Last Sex
Charlotte Pearl Reinertsen Female
Date of Death Age If Veteran of U.S. Armed Forces,
June 22, 2017 84 War or Dates
Place of Death Hospital, Institution or
uj City, Town or Village Hudson Falls Street Address 5G Earl Towers
-
WManner of Death X❑Natural Cause El Accident El Homicide p Suicide riUndetermined ❑ Pending
0 Circumstances Investigation
P Medical Certifier Name f SILL I ti 1- L0 Title MD
Address
I 3 n R otJ F CEO . ANC F4u- l awl,
Death Certificate Filed District Number Register Number
City, Town or Village S 7 l 01 / /
Ci ❑Burial Date LQ /1,3 / t Cemetery or Crematory
Pine View Crematorium
0 Entombment Li fv, Address
Cremation Quaker Road Queensbury,NY 12804
ii %° Date Place Removed
0❑ Removal
and/or and/or Held
Hold
Address
ti, Date Point of
tt
❑Transportation Shipment
by Common Destination
iisi Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
_ , Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
v Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
`, Remains are Shipped, If Other than Above
IAddress
lA
>t.. Permission is hereby granted to dispose of the human remains described above as indicated.
_1:. Date Issued 6/)-3 //? Registrar of Vital Statistics
(signature)
District Number S)6 Place --TOwh J[ k;i'S-s.L (7-4-ci
J
i:2 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Lu Date of Disposition 411L010 Place of Disposition Quaker Road Queensbury,NY 12804
X (address)
W Parents Lot
UT.
-may (section) (lot number) JSimitia (grave number)
` ' Name of Sexton or Person in Charge of remises G� � pl�-�I
1 (please dent) �
Signature h Title C1 MV t
(over)
DOH-1555 (02/2004)