Locke, Christine NEW YORK STATE DEPARTMENT OF HEALTH RI
r 1�,Vital Records Section Burial - Transit Permit
' Name First ,e Last Sex
Christine Mary • Locke Female
Date of Death Age If V Ian of U.S. Armed Forces,
October 7, 2C11 58 War or Dates
I- Place of Death Hospital, Institution or
W City, Town or Village Glens Falls Street Address Glens Falls Hospital
E Manner of Death J Natural Cause ❑ Accident Homicide Suicide Undetermined Pending
WCircumstances Investigation
W Medical Certifier Name Title
CZ- John Stoutenberg MD, M.D. Dr.
Address
102 Park St. Glens Falls, NY 12801
Death Certificate Filed District Number Regist�r�lmber
City, Town or Village 5601 f�(�/
❑Burial Date Cemetery or Crematory
October 10, 2011 Pine Vew Crematorium
❑Entombment Address
®Cremation Queensbury,NY 12804
Date Place Removed
• Removal and/or Held
a and/or Address
E; Hold Pine View Crematorium
fl} Date Point of
ci. Ei Transportation Shipment
U?' by Common Destination
C 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
F Remains are Shipped, If Other than Above
2 Address
Lit'
d" Permission is hereby granted to dispose of the human remains describ o e a dic• .
Date Issued !0w`20// Registrar of Vital Statistics
�l �^C� /ice- (signature)
District Number 5601 Place 'y/�
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition f01ri ,it Place of Disposition .,pA.,Ut(v) C"Aor,I,if,
2` (address)
Ui
(1)
re (section) (lot numb
Q Name of Sexton or Per n in Charge of remises CLAivi.cr. 3 (grave number)
z
rw�[4
(please print)
W Signature Title Cczr ftlft/tI -
(over)
DOH-1555 (02/2004)