Sexton, Louise NEW YORK STATE DEPARTMENT OF HEALTH ' R` 4 J�,1
Vital Records Section Burial - I ransit Permit
Name First Middle Last Sex
female
Louise K. ScYJ-_Oil
Date of Death Age If VetglNan of .Armed Forces,
Mar 2, 2016 95 War orDat _0_
Place of Death Hospital, Ins tion or
City, Towrk/i#lage Glens Falls Street Ad ss Glens Falls Hospital
Manner of Death LxicNatural Cause 0 Accident Homicide Q Suicide Undetermined El Pending
Circumstances Investigation
4 Medical Certifier Name Title
9 Melissa nedeer, MD
av 0 :W Address
Death CirtilkaP Filefy' NY District Number Register/fiber
City, Town 3tla xx Glens Falls 5601
❑Burial Date Cemetery or Crematory
El Entombment Marcb 4, 2016 Pine View Crematorium
Address
[]Cremation Tn of Qii ensl-mr.y, NY
Date Place Removed
Removal and/or Held
and/or
Hold Address
Date Point of
fa El Transportation p Shipment
by Common Destination
a Carrier
4n Date Cemetery Address
- El Disinterment
0 Reinterment Date Cemetery Address
AN-
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
7'1 Address
H son Falls NY 12839
Name of Funeral Firm Ma ing Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby ranted to dispose of the human remains describ boe in d.
D
Date Issued 3/0"7 ZDlG Registrar of Vital Statistics /�"
(signature)
District Number
Place
5601 city of Glens Falls
N I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 3/$/j(, Place of Disposition gjad m ct.,
1 (address)
lifej (section) dti-ittyv-
(tot number) (grave number)
6
Name of Sexton or Person in Charge Premises �d'►AIG+'
( ase print)
' Signature . ' Title WA'1 f7 ,
(over)
DOH-1555 (02/2004)