LaCarte, Virginia NEW YORK STATE DEPARTMENT OF HEALTH 41/
Vital Records Section Burial - Transit Permit
F. i
Name First Middle Last Sex
Virginia Adeste LaCarte Female
Date of Death Age If Veteran of U.S. Armed Forces,
September 6, 2011 83 4;`-"- War or Dates
Z' Place of Death Hospital, Institution or
rri City, Town or Village Wilton street Address 27D Adirondack Circle
W+ Manner of Death 1J Natural Cause ❑ L__f Accident Homicide El Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
WW Medical Certifier Name Title
Christopher Hoy MD,
Address
Suite C Glens Falls, NY 14301
Death Certificate Filed - District Number Register Number i.
City,(Fownn)r Village VA i (koY"
❑Burial Date Cemetery or Crematory
September 6, 2011 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
H Hold
Pine View Crematorium
CD Date Point of
a. ❑Transportation Shipment
CO by Common Destination
a Carrier
Date Cemetery Address
❑ Disinterment
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
1-- Remains are Shipped, If Other than Above
2 Address
Ce
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued / Registrar of Vital Statistics '/,Zs/ /� ( ;4 �
�Y signature)
District Number .�/� Place 4,07 / %,� (9
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
uj Date of Disposition 1($III Place of Disposition
W (address)
Ce 04 .(section) (lot num9`) (grave number)
C Name of Sexton or Person in Charge f Premises �' 3gdor
Z
(please print)
W Signature Title CpFM 1'ek
(over)
DOH-1555 (02/2004)