Langworthy, Elizabeth NEW YORK STATE DEPARTMENT OF HEALTH - r45, Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Elizabeth
Wykes Langworthy Female
: >. Date of Death Age If Veteran of U.S. Armed Forces,
January 12, 2011 82 War or Dates
kl Place of Death Hospital, Institution or
.. City, Town or Village Queensbury Street Address 35 Evergreen Lane Apt 101
• Manner of Death X Natural Cause Accident ❑ Homicide ❑ Suicide ❑ Undetermined Pending
r4. ❑ ❑ Circumstances Investigation
Medical Certifier Name Title
A. Thomas Coppins, M.D
Address
Irongate Center Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village 610 S7 V
• ❑Burial Date Cemetery or Crematory
January 14, 2011 Pine View Crematorium
❑Entombment Address
Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold Pine View Crematorium
Date Point of
iv n Transportation Shipment
by Common Destination
Carrier
❑
Date Cemetery Address
Disinterment
ii❑ Reinterment Date Cemetery Address
. Permit Issued to Registration Number
• Name of Funeral Home Carleton Funeral Home, Inc. 02043
Address
Carleton Funeral Home, Inc. 136 Warren St., P.O. Box 612 Glens Falls, NY 12801
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains des ribed ov as'indicated.
Date Issued ! i -',t t Registrar of Vital Statistics (,y2 � _
(signature)
District Number c-7 Place a�
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 01/14/2011 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) _ (lot number)<. (grave number)
Name of Sexton or P son. in Charge f,,Premises (Lr1 )ur St N Nti
(please print)
Signature Title '-i vi IV 0 t I
(over)
DOH-1555 (02/2004)