McCrea, Dale NEW YORK STATE DEPARTMENT OF HEALTH ,
Vital Records Section Burial - Transit Permi _
Name First Middle Last Sex
Date Ann McCrea Male
Date of Deathtzt Age If Veteran of U.S. Armed Forces,
January 24, 2017 77 War or Dates
tt` Place of Death Hospital, Institution or
tJ. City, Town or Village Glens Falls Street Address Glens Falls Hospital
iD' Manner of DeathLni Natural Cause Accident � Homicide � Suicide � Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Michael Fuller, M.D
Address
100 Park Street Glens Falls, NY 12801
, Death Certificate Filed District Number Register Number 6a1
`' City, Town or Village
I❑Burial Date Cemetery or Crematory
1 /2 7/2 01 7 Pii4eview) Qremat`nrium
ag❑Entombmem Address
[ICremation Town of Queensbury, NY
Date Place Removed
Removal and/or Held
and/or Address
Hold Pine View Crematorium
Date Point of
u. ❑Transportation Shipment
0' by Common Destination
Carrier
Disinterment Date Cemetery Address
Li
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
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
s Date Issued . if 27 b C 7 Registrar of Vital Statistics (.../j c, y r'& Li .),..A--/•.-Ncp".
(signature)
_; District Number 5 hot Place EE (-Q.,�'\s j - `\S l v
1'
'14-:,
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tu Date of Disposition 01/27/2017 Place of Disposition ?last✓ Cr'a&tOt+ _
Z (address)
,iii
:
0.0g (section) (lot number) SPI-id
(grave number)
tri Name of Sexton or Person in Charge of remises �/ s
' -$ (pl sse print)' ,^Signature A Title (pfMA.
(over)
DOH-1555 (02/2004)