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French, Rita NEW YORK STATE DEPARTMENT OF HEALTH �I Vital Records Section Burial - Tranlit Permit - Name First Middle Last Sex Rita Ann French Female Date of Death Age If Veteran of U.S. Armed Forces, January 20, 2017 90 War or Dates I- Place of Death Hospital, Institution or tCity, Town or Village Saratoga Springs Street Address Saratoga Hospital 0= Manner of Death ❑Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending W; Circumstances Investigation W Medical Certifier Name Title Address Death Certificate Filed District Number��I Register Number 3 City, Town or Village ❑Burial Date Cemetery or Crematory January 25, 2017 Pine View Crematorium ❑Entombment Address ©Cremation _ Quaker Road Queensbury,NY 12804 Date Place Removed z ❑ Removal and/or Held and/or Address E Hold Pine View Crematorium 0 Date Point of a ❑Transportation Shipment ) by Common Destination °0 Carrier Date Cemetery Address ❑ Disinterment ❑ 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 II—. Remains are Shipped, If Other than Above 2 Address IX a.f Permission is ereb granted to dispose of the human remai ib ab°i9 ' dicated Date Issued I 21-1 Registrar of Vital Statistics f - (signature) District Number 4501 Place , Jl , 3pri S. Fy I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 01/25/2017 Place of Disposition Quaker Road Queensbury,NY 12804 MT (address) tii (') (section) /°f lot number) (grave number) ice' Name of Sexton or Person in Charge of Premises L kr,.t Ste'"1/t Z (plelise print) LCI Signature Title f(:F_M L (over) DOH-1555 (02/2004)