Forcht, Marietta it
NEW YORK STATE DEPARTMENT OF HEALTH It (15-
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Marietta T. Forcht Female
giii
Date of Death Age If Veteran of U.S. Armed Forces,
02/07/2017 75 years War or Dates
`-- Place of Death Hospital, Institution or
Z City, TO(i ( MOW Glens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause Ej Accident 0 Homicide Suicide ElUndetermined 0 Pending
in
Circumstances Investigation
ui Medical Certifier Name Title
William Cleaver Attending Physician
Address
100 Park St Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
ft City, TdWHOir➢(MX Glens Falls 5601 90
ilil❑Burial Date Cemetery or Crematory
02/09/2017 Pine View Crematory
❑Entombment Address
'i[]'Cremation Queensbury, NY
Date Place Removed
❑and/or Address
Removal and/or Held
(;,;;;
Hold
Date Point of
cnCL El Transportation Shipment
C by Common Destination
iiiiii Carrier
Q Disinterment Date Cemetery Address
[]• Reinterment Date Cemetery Address
< Permit Issued to Registration Number
Name of Funeral Home Edward L. Kelly Funeral Home 00519
Address
Schroon Lake, N Y 12870
il Name of Funeral Firm Making Disposition or to Whom
14. R• emains are Shipped, If Other than Above
'; Address
re
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'` P• ermission is hereby granted to dispose of the human remains described above as indicated.
'.`i?i Date Issued 02/09/2017 Registrar of Vital Statistics t,'o...t,-y.L
(signature)
lili District Number 5601 Place Glens Falls�Ary
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
IU Date of Disposition 210)0 Place of Disposition n,cj, (4 +a{dr..,.
2 (address)
ILI
CC (section) ,clot number) (grave number)
O.
ci Name of Sexton or Person in Charge of Premises t
(pie e print) Sod%
i
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gi Signature Title ` tV i7 `Z,
(over)
DOH-1555 (02/2004)