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Greene, Diana NEW YORK STATE DEPARTMENT OF HEALTH R �S L Vital Records Section Burial - Transit Permit } i Name First Middle Last Sex Diana Marie Greene Female Date of Death Age If Veteran of U.S. Armed Forces, May 13, 2011 50 War or Dates Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death i Natural Cause 0 Accident 0 Homicide 0 Suicide LiUndetermined Pending Circumstances Investigation Medical Certifier Name Title Suzanne M Blood, MD, Address 14 Manor Dr. Queensbury, NY 12804 Death Certificate Filed District Number J Register j b�,r City, Town or Village �- p�' ❑Burial Date Cemetery or Crematory May 18, 2011 Pine Vew Crematorium ❑Entombment Address ©Cremation Queensbury,NY 12804 Removal Date Place Removed El and/or and/or Held Hold Address Date Point of Transportation Shipment by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address 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 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address Permission is h eb granted to dispose of the human remains descri a ab ve/ ind. Date Issued 6 Registrar of Vital Statistics � ll� `r� � cc(iy�ss (signature) District Number Sbri Place 6k4S/ t4 �j /°4'( I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition S-1S -1t Place of Disposition Pine UltuJ Crrtn.,tar:... (address) (section) - (lot number) (grave number) Name of Sexton or Pero in Charge of remises (.01 r —�tOr& please print) Signature g Title CIlEM110S� (over) DOH-1555(02/2004)