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Palmer, Geneva NEW YORK STATE DEPARTMENT OF HEALTH° ' 1 Z Vital Records Section Burial - uransit Permit Name First Middle Last Sex Geneva Grace Palmer Female Date of Death Age If Veteran of U.S. Armed Forces, October 3, 2016 90 War or Dates 1 Place of Death Hospital, Institution or A W City, Town or Village Fort Edward Street Address FORT HUC EALTH CARE FAC. C) Manner of Death [Natural Cause ElAccident ElHomicide ❑ Suicide El U ned ❑ Pending Investigation W Medical Certifier Name Title CI Philip Gara, M.D. Dr. Address Broadway Fort Edward, NY 12828 Death Certificate Filed District Nump ri 5� Register Number5 City, Town or Village �� ❑Burial Date Cemetery or Crematory October 4, 2016 Pine View Cremat, ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed ElRemoval and/or Held - and/or Address Hold Date Point of a. ❑Transportation Shipment CO by Common Destination O' Carrier Date Cemetery Address I I Disinterment Date Cemetery Address ❑ Reinterment 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 :' Address I W Permission is hereby granted to dispose of the huma`re ins described a�bpve a 'ndicated. Date Issued I O�`{ J L( , Registrar of Vital Statistics e ) V �' (signature) District Number5155 Place_ 7-6. Q/(Q� I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I !J Date of Disposition 10/04/2016 Place of Disposition Quaker Road Queensbury,NY 12804 2 (address) W (section) /��lot number) (grave number) ci Name of Sexton or Person in Charg of Premises [L fa"OQ4r- St14i ' z (piealse print) W Signature A, Title C (over) DOH-1555 (02/2004)