Martin, Dorothea NEW YORK STATE DEPARTMENT OF HEALTH
# y$7
Vital Records Section Burial - Transit Permit
E_, Name First Middle Last Sex '-w,t,(c_
4„ir Dorothea Elizabeth Martin Male
kg-. Date of Death Age If Veteran of U.S. Armed Forces,
July 6, 2016 93 __War or Dates
Place of Death Hospital, Institution or
w' City, Town or Village Granville Street Address INDIAN RIVER REHAB &HLTH CARE
Manner of Death 0 Natural Cause 0 Accident D Homicide D Suicide r-iUndetermined ri❑ Pending
Circumstances Investigation
14 Medical Certifier Name Title
JP-
Thomas F Kandora, M.D
Address
7240 Upper Broadway Fort Edward, NY 12828
Death Certificate Filed / District Number Register N mber
pggh City, Town or Village rAtd ii'/� 57975- (- C
``€❑Burial Date Cemetery or Crematory
July 8, 2016 Pine View Crematorium
gv ❑Entombment Address
IAA®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
,i,in Removal and/or Held
tog I—I and/or Address
Hold
Date Point of
4 0 Transportation Shipment
0)= by Common Destination
,40 Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
-4144
ri, Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
g4'4. 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
IL Permission is hereby gra ted to dispose of the human re ns deiiii;d e as indicated.
444-14 Date Issued ��� j Registrar of Vital Statistics
(signature)
�4 Airy
District Number cc7c2 5 Place '//I/t'
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
t-r-
iii Date of Disposition 07/08/2016 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
it
(section)
(lot number) (grave number)
ggot Name of Sexton or Person in Charge of Premises 6 I
,•9I' '" it.,gti�f-
( lease print)
W Signature LC- Title CiEM a_
(over)
DOH-1555 (02/2004)