Phelps, Michele NEW YORK STATE DEPARTMENT OF HEALTH' , ! -?
Vital Records Section Burial - Transit Permit
A
Name First " Middle Last Sex
�' Michele Phdebe Phelps Female
r`$ Date of Death Age If Veteran of U.S. Armed Forces,
April 25, 2017 46 War or Dates
Place of Death Hospital, Institution or
1. City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death�Natural Cause ❑ Accident El Homicide Ej Suicide Undetermined ri Pending
Circumstances Investigation
. Medical Certifier Name Title
Darci Gaiotti-Grubbs, Dr.
,` Address
102 Park Strut Glens Falls, NY 12801
Death Certificate Filed District Number Register Number �,
City, Town or Village ' )0 i L, �C�`
Date
,-;❑Burial April 27, 2017 Cemetery or Crematory
Pine View Crematorium
❑Entombment Address
1 ®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
Removal and/or Held
and/or Address
Hold
f,_.41 Date Point of
IL-
Transportation Shipment
by Common Destination
la Carrier
to Disinterment Date Cemetery Address
Date CemeteryAddress
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
_' Remains are Shipped, If Other than Above
F : Address A Permission is hereby granted to dispose of the human remains de ribed abov as indicat-d.
Date Issued Q Registrar of Vital Statistics i/Z-g-P—ie,7 �`', .-A- �'
` >lgnature)
District Number / Place __.---)&24ft. 6Z—ea
I certify that the remains of the decedent identified above were disposed of in accord nce with this permit on:
Date of Disposition 04/27/2017 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) , , (lot number) . (grave number)
Name of Sexton or Person in Charge of Premises L ifr-
,,
L lease print)
OP
Signature Title Ai Em Vt'1_
(over)
DOH-1555 (02/2004)