Walden, Regina ¢+ a la i
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
1 Name First Middle Last Sex
Regina Marie Walden Female
Date of Death Age If Veteran of U.S. Armed Forces,
November 8, 2011 81 War or Dates
li Place of Death Hospital, Institution or
W City, Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death 0 Natural Cause 0 Accident 0 Homicide 0 Suicide 0 Undetermined 0 Pending
W Circumstances Investigation
WW Medical Certifier Name Title
Joseph C. Mihindu, MD,
Address
20 Murray Street Glens Falls, NY 12801 (�
Death Certificate Filed District Numb [ o Registe
City, Town or Village
1
0 Burial Date Cemetery or Crematory
November 14, 2011 Pine View Crematorium
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z 0 Removal and/or Held
O and/or Address
H Hold
CO Date Point of
0
0 Transportation Shipment
V_1 by Common Destination
O Carrier
Disinterment Date Cemetery Address
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
}— Remains are Shipped, If Other than Above
2 Address
la
0,.. Permission is hereby granted to dispose of the human remains sgribe ve icated.
Date Issued // /®,10 Registrar of Vital Statistics ,� Gic
/� �/` � (signature)
District Number ,S"�,Q/ Place t° s
I certify that the remains of the decedent identified above were disposed of ini(�accordance with this permit on:
wDate of Disposition pov `sl Tot\Place of Disposition emu.U. (v+mc,0,,„,...
W (address)
CO
0' (section) 4 (Jot number) (" (grave number)
C1; Name of Sexton or Per in Chargej, isesnst Oz (p/ee print)
/W SignatureTitle CQ ern IR-
(over)
DOH-1555 (02/2004)