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Manell, Charlene NEW YORK STATE DEPARTMENT OF HEALTH � ' • • 3)q Vital Records Burial TransitP rtn 1 eco ds Section e t Ilk Name First Middle Last Sex *, Charlene M Manell Female '`c a Date of Death Age If Veteran of U.S. Armed Forces, P.fi ' May 8, 20 63 War or Dates Place of Dea Hospital, Institution or w City, Town or Village Hudson Falls Street Address 8 Pearl Street, Apt 3 W: Manner of Deat © Natural Cause ❑ Accident El Homicide El Suicide ❑ Undetermined ri❑ Pending Circumstances Investigation is Medical Certifier Name Title Ll- Thomas Portuese, Dr. Address 100 Broad St. Glens Falls, NY 12801 Death Certific 0� Fi d District Number Register Number :' City, Town o<Village) u"Lka s c+t> emu.( (S 57.4 8 0 Burial safe Cemetery or Crematory May 9, 2017 Pine View Crematorium IV❑Entombment Address ®Cremation Quaker Road Queensbury,NY 12804 Date Place Removed ❑ Removal and/or Held and/or Address Hold ' ' Date Point of 40 ixt❑Transportation Shipment , Q by Common Destination Carrier ❑ Disinterment Date Cemetery Address ' El Reinterment Date Cemetery Address t . 1 Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home, Inc. 00281 a 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 t:' Remains are Shipped, If Other than Above Address Ir W` Permission is hereby granted to dispose of the human ' s described above as indicated. Date Issued J`1 8"/7 Registrar of Vital Statistics (t)o h i ,- -_---- (signature) c,,,;,,,,, � 'District Number C Place , )� �s tip' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: us,j Date of Disposition 05/09/2017 Place of Disposition Quaker Road Queensbury,NY 12804 (address) W: (section) (lot number) r (grave number) _a_ Name of Sexton or Person in Charge of remises 7��� �'+ , ►u /f� (else print) W Signature G�' M R- g Title i (over) DOH-1555 (02/2004)