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Quinn, Constance NEW YORK STATE DEPARTMENT OF HEALTH `� (13G Vital Records Section Burial - Tiltansit Permit Name First Middle Last Sex Constance Michelle Quinn Female Date of Death Age If Veteran of U.S. Armed Forces, June 13, 2016 59 War or Dates E Place of Death Hospital, Institution or W City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death Natural Cause 0 Accident Homicide 0 Suicide Undetermined Pending W' Circumstances Investigation W Medical Certifier Name Title d' N. Balasubraniam MD, Address New Scotland Ave Albany, NY 12205 Death Certificate Filed District Number 5 G ' 0 Registter Number City, Town or Village ❑Burial Date Cemetery or Crematory June 15, 2016 Pine View Crematorium 0 Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z ❑ Removal and/or Held and/or Address .' Hold GI Date Point of i�1.'❑Transportation Shipment CO by Common Destination L'i 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 1-- Remains are Shipped, If Other than Above ▪ Address CC 1 Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 6 ` l 5 1/6 Registrar of Vital Statistics N..A # "Q (,,A)--,V\-y' ",, (signature) District Number 5 6 0I Place 6 c \,\s , pJ u I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: /G w Date of Disposition 06/ /2016 Place of Disposition Quaker Road Queensbury,NY 12804 2 (address) W CO re (section) (lot number) (grave number) Name of Sexton • P- -•,,'n Charge of Premises �H fi ti.1 64.41ae-4� z /_'/� (please print) W Signature '!.. Title Gre/n�4-0E- / (over) DOH-1555 (02/2004)