Mundell, Maryann NEW YORK STATE DEPARTMENT OF HEALTH 4 . ` ? If IL
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Maryann Mundell Female
Date of Death Age If Veteran of U.S. Armed Forces,
January 28, 2017 59 War or Dates
Place of Death Hospital, Institution or
City, Town or VillageILI Glens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause ❑ Accident El Homicide ❑ Suicide 0 Undetermined El❑ Pending
1.1JCircumstances Investigation
LU Medical Certifier Name Title
Mark Quaresima, M.D
Address
Moreau Family Health
. Certificate Filed District Number Register ber
City, own or Village �� (e r�5 ra j I s J5(oO( �
• :urial Date Cemetery or Crematory
February 2, 2017 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
. Hold
FA Date Point of
0. ❑Transportation Shipment
ft) by Common Destination
a Carrier
❑ Disinterment Date Cemetery Address
Date Cemetery Address
❑ 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
I- Remains are Shipped, If Other than Above
Address
I<i:` Permission is hereby ranted to dispose of the human remains de ribe a ve cated.
Date Issued a 3o 20/2 Registrar of Vital Statistics
(si nature) •
District Number 06(,/ Place 67.e.y.,.,„' `/, 11-). J
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 02/02/2017 Place of Disposition Quaker Road Queensbury,NY 12804
2 (address)
W'.
iX (section)- i/t i (lot number) (grave number)
lName of Sexton or Person in Charge of Pr ises host Sfri‘l it
(p ea ,�se print)fh��
al Signature Lill Title ti
(over)
DOH-1555 (02/2004)