Morrissey, Diana NEW YORK STATE DEPARTMENT OF HEALTH' . , _, #Vital Records Section Burial - TransitVt;
rmit
Y Name First Middle Last Sex
;= Diana Lynn Morrissey Female
Date of Death Age If Veteran of U.S. Armed Forces,
June 21, 2017 55 War or Dates
� Place of Death Hospital, Institution or
' City, Town or Village Albany Street Address Albany Medical Center
Manner of Death Natural Cause 0 Accident 0 Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name frtT:Itle
avivl0n Address
D h Certificate Filed J District Number Regis er Number �"
i own or Village Alt\o&,z / 33
})'❑Burial Date ( Cemetery or Crematory
Pine View Crematorium
41,.4,❑Entombment Address
2,®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
Transportation Shipment
E by Common Destination
ACarrier
af ❑ 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
jName of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is h reby ranted to dispose of the human mains describe above as indicated. l7L.,.
Date Issued a 3 20/ Registrar of Vital Statistics
(signa ure)
.' District Number Place
g 0 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
t:-
a Date of Disposition 6/L7 1 j1Place of Disposition Quaker Road Queensbury,NY 12804
2: (address)
'w;
Et (section) /�/(lot number) c (grave number)
gr Name of Sexton or Person in Charge of Premis L rins �L04
(p1 irk,
print
4 Signature Title nt
(over)
DOH-1555 (02/2004)