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McCarthy, Diane Mr it 7 70 NEW YORK STATE DEPARTMENT OF HEALTH '�Vital Records Section Burial - Transit Permit ' Name First Middle Last Sex Diane June McCarthy Female C Date of Death Age If Veteran of U.S.Armed Forces, 10/21/2017 85 Years War or Dates Place of Death Hospital, Institution or ifi City, Town or Village Glens Falls Street Address Glens Falls Hospital p Manner of Death©Natural Cause ❑Accident ElHomicide ❑Suicide ❑Undetermined ❑Pending Circumstances Investigation 0 ui Medical Certifier Name Title i. Nawed Siddiqui MD `` Address t" 100 Park St,Glens Falls,New York 12801 Death Certificate Filed I - ,ct Number Register Number City, Town or Village Glens Falls u01 546 ▪ ❑Burial Date Cemetery or Crematory i 10/24/2017 Pine View Crematorium ❑Entombment Address El Cremation Queensbury Town, New York Date Place Removed 1❑Removal and/or Held and/or Address F Hold CO O Date Point of N❑Transportation Shipment a by Common Destination Carrier ▪ ❑Disinterment Date Cemetery Address ', ❑Reinterment Date Cemetery Address y Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Stpo Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom P4. Remains are Shipped, If Other than Above 3 Address `Ltd ,' Permission is hereby granted to dispose of the human remains described above as indicated. y i; Date Issued 10/24/2017 Registrar of Vital Statistics 4,6ertACurtis ErectronicallySigned (signature) E';, District Number 5601 Place Glens Falls, New York 1 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z �r Date of Disposition /) inh0 Place of Disposition �N,i.�,/ ae.kor.,.. in (address) 0 1:4 (section) (lot 7rmber) (grave number) p; Name of Sexton or Person in Charge of Pr mises p 7 -J St" Zr (pse print) In el ig MA, Signature Title (over) DOH-1555 (02/2004)