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Prevost, Catherine NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section . . Burial - Transit Permit Name First Middle Last Sex Catherine Ann Prevost Female Date of Death Age r If Veteran of U.S. Armed Forces, June 20, 2016 76 War or Dates I Place, ath Hospital, Institution or W Cit( own r Village m 0 u--e a Street Address 17 Willow Street CI W Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide El Suicide ❑ Undetermined ❑ Pending Circumstances Investigation W Medical Certifier Name Title Ct Robert Beaty MD, Address 100 Broad St. Glens Falls, NY 12801 Death . icate Filed District Number Register Number City, own r Village �"Y) 0 r eaa ir-� • 0 Burial Date Cemetery or Crematory June 24, 2016 Pine View Crematorium ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed ❑ Removal and/or Held and/or Address H Hold th Date Point of Oa. ❑Transportation Shipment C by Common Destination in Carrier Date Cemetery Address III Disinterment Date Cemetery Address El 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 F. Remains are Shipped, If Other than Above 2 Address W a' Permission is e by granted to dispose of the human rs de r b ab ve as indicated. Date Issued / Registrar of Vital Statis ict s but' (signature) District Number 7 a-- Place 3S7 / Li1?o as )e,. Q af 1 IGY / a(1 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition 06/24/2016 Place of Disposition Quaker Road Queensbury,NY 12804 2" (address) W CO [C (section) (lot number) (grave number) iLp, Name of Sexton or Person in Charge of Premises A 30,17 Z a__ (please print) W Signature Title Crthwi (over) DOH-1555 (02/2004)