Hagan, Nancy NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit `�
Name First Middle Last Sex
Nancy _ Hagan Female
Date of Death Age If Veteran of U.S. Armed Forces,
October 1, 2011 88 War or Dates
12 Place of Death Hospital, Institution or
u City, Town or Village Cleverdale Street Address 233 Cleverdale Road
w Manner of Death Natural Cause Accident Homicide Suicide El Undetermined Pending
Circumstances Investigation
WWW Medical Certifier Name Title
Daniel Way, M.D Dr.
Address
North Creek Health Ctr Warrensburg, NY
Death Certificate Filed Di tr' t Number Register Number
City, Town or Village 1� cL
[]Burial Date Cemetery or Crematory
October 3, 2011 Pine Vew Crematorium
❑Entombment Address
®Cremation Queensbury,NY 12804
Date Place Removed
z � Removal and/or Held
p; and/or Address
_p Hold
U? Date Point of
❑Transportation Shipment
N' by Common Destination
5 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
Remains are Shipped, If Other than Above
2 Address
W;
Permission is hereby granted to dispose of the human re sins describedAoxe as indicated.
Date Issued 0t .1 l d t1Registrar of Vital Statistics c C\ ,
(signature)
District Number c(9S'"--) Place
I certify that the remains of the decedent identified above were disposed of in accord4 with his permit on:
Lu Date of Disposition t O-5—1 Place of Disposition Cr^sz ec j ium
W (address)
te (secctioonn pot number) (grave number)
Name of Sexton or Person in Charg of Premises(s t Z c,$ky (�f uri�IIC'
(please print) /
Signature ��yra Title ct eA,a�c,�y Asst.
(over)
DOH-1555 (02/2004)