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Mattison, Deborah NEW YORK STATE DEPARTMENT OF HEALTH t 1 r ' Burial - ra�it Permit Vital Records Section Name First Middle Last Sex Deborah Lynn Mattison Female Date of Death Age If Veteran of U.S. Armed Forces, November 26, 2016 63 War or Dates F- Place of Death Hospital, Institution or W City, Town or Village Fort Edward Street Address 2358 Route 4, Fort Edward, NY 12828 CI Manner of Death mIJ Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined. ❑ Pending 0 Circumstances Investigation W, Medical Certifier Name Title CI Danushan Sooriabalan, M.D Address 161 Carey Road Queensbury, NY 12804 Death Certificate Filed District Number Register umber City, Town or Village .S 5:.S" s-e ❑Burial Date Cemetery or Crematory November 28, 2016 Pine View Crematorium ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z ❑ Removal and/or Held • and/or Address p Hold Pine View Crematorium Date Point of a.. ❑Transportation Shipment ca by Common Destination 8 Carrier ElDisinterment Date Cemetery Address ElReinterment 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 H Remains are Shipped, If Other than Above 2 Address 4' W • Permission is h eby granted to dispose of the huma em ns described ab ve as i mated. Date Issued 10 Registrar of Vital Statist s 0 (signature) District Number5)5 Place /�-CY' 7 ---12.- C � I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition 11/28/2016 Place of Disposition Quaker Road Queensbury,NY 12804 (address) W, 'CO W (section) // (lot number) (grave number) =g- Name of Sexton or Person in Charge of Premises L 9rs + St lit (please print) • Signature 01 i Title Cgfttl14 (over) DOH-1555 (02/2004)