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Young, Eleanor NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Vital Records Section Name First Middle Last Sex Eleanor Young Female Date of Death Age If Veteran of U.S. Armed Forces, May 21, 2016 91 War or Dates ZPlace of Death Hospital, Institution or itCity, Town or Village Fort Edward Street Address FORT HUDSON HEALTH CARE FAC. Ca Manner of Death a Natural Cause 0 Accident ❑ Homicide Suicide Undetermined Pending W Circumstances Investigation U W Medical Certifier Name Title P Philip Gara, M.D. Dr. Address Broadway Fort Edward, NY 12828 Death Certificate Filed District Number 5,55 umber RegisterD City, Town or Village ,J ❑Burial Date Cemetery or Crematory May 24, 2016 Pine View Crematorium ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z Removal and/or Held and/or Address Hold N Date Point of Et. 0 Transportation Shipment fl! by Common Destination 3` Carrier Disinterment Date Cemetery Address ElReinterment 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 I Remains are Shipped, If Other than Above 2 Address CC W' Cl. Permission is hereby granted to dispose of the human ins described o indicated. Date Issued Q5-a3-I 6 Registrar of Vital Statistics 4 District Number(.5'755 Place �,(�-� �.,� ( ' ature V U 1� I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: i�i,i Date of Disposition 05/24/2016 Place of Disposition Quaker Road Queensbury,NY 12804 2' (address) W'' 0) ce (section) 1 (lot nmbe) „A (grave number) p. Name of Sexton or Person in Charg of Premises 74'(1���.y,A� Stv"r' Z �� (pl8ase print) Signature Title 1111 fit (biz (over) DOH-1555 (02/2004)