Olton, Jean NEW YORK STATE DEPARTMENT OF HEALTH s % �S
Vital Records Section Burial - Transit Permit
- Name First Middle Last Sex
Jean S Olton ,. • Female
Date of Death Age If Veteran of U.S. Armed Forces,
January 24, 2017 99 War or Dates
I- Place of Death Hospital, Institution or
r= City, Town or Village Fort Edward Street Address FORT HUDSON HEALTH CARE FAC.
W Manner of Death iv,
Lai Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
0 Circumstances Investigation
W Medical Certifier Name Title
CI (ifal1. M.:RAid f2MC -
Address
qfce, pRotiflI,oAL foRT �DY Nm. IZsZg
Death Certifica .lrjl d District Amber Register Number
City, Town orii PFT 444(1110
❑Burial Date Cemetery or Crematory
January 27, 2017 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
z Date Place Removed
❑ Removal and/or Held
O and/or Address
E Hold
,
O Date Point of
p„ ❑Transportation Shipment
0) by Common Destination
CI Carrier
Date Cemetery Address
❑ Disinterment
❑ 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
I--- Remains are Shipped, If Other than Above
• Address
IX
W
C'r Permission is hereby granted to dispose of the hums re ins dq c above as indicated.
`` Date Issued I—p�7aa f Registrar of Vital Statistics V-
/ J� �(signatur
District Number`50.65 Place ��5-u9� C%llw
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 01/27/2017 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
W,
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I (section) /. (lot number) (� (grave number)
0 Name of Sexton or Person in Charge of7misesz
_ ( lease print)
W Si nature 4✓� / Title9 �
(over)
DOH-1555 (02/2004)