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Streeter, Samantha NEW YORK STATE DEPARTMENT OF HEALTH II Vital Records Section Burial - Transit Perhiit f Name First Middle Last Sex 004, Samantha Elise Streeter Female . Date of Death Age If Veteran of U.S. Armed Forces, '. _ February 8, 2011 22 War or Dates Place of Death Hospital, Institution or 2 City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death❑ Natural Cause ❑ Accident 0 Homicide ❑ Suicide ❑ Undetermined Pending Circumstances Investigation a Medical Certifier Name Title Address V4- I / at Death Certificate Filed Number b City, Town or Village `eos it. 1 61Lo ` ❑Burial Date Cemetery or Crematory�� ( 2- ��� Pine View Crematorium .,.❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 ❑ Removal Date Place Removed ' and/or and/or Held Hold Address Date Point of , ❑Transportation Shipment by Common Destination Carrier El Disinterment Date Cemetery Address x- ❑ Reinterment Date Cemetery Address e. -� Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home, Inc. 00276 Address Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839 :'' 'fi Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 21 i/ // / Registrar of Vital Statistics i_.A2cA.A.4-\,,Q .j ." "r3 . (signature) District Number 5"60 r Place 6 Uz,./ .s VCk kk S k.)cf./ 3 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: �A ,r Roau „_.i,;, 128nd Date of Disposition ' ,►� 2041 Place of Disposition y IZ'4A,. /dv. 1 (address) ' , (section) (lot nymber) (grave number) Name of Sexton or P son in Charg f Premises CI.f,y}cfitr ery,A ( (please print) Signature 1 Title (I2E1A-`' (over) DOH-1555 (02/2004)