Connery, Priscilla NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section -N Burial - Transit rermit
Name First Middle Last Sex
Priscilla B. Connery Female
Date of Death Age If Veteran of U.S. Armed Forces,
September 27, 2011 81 War or Dates
Place of Death Hospital, Institution or
Lii City, Town or Village Fort Edward Street Address FORT HUDSON HEALTH CARE FAC.
W Manner of Death 0 Natural Cause ElAccident 0 Homicide n Suicide 0 Undetermined ❑ Pending
Circumstances Investigation
Ill_ Medical Certifier Name Title
CI Robert L Evans DO,
Address
1 Irongate Center Glens Falls, NY 12801
Death Certificate Filed District Number Re inter Number
City, Town or Village .6-253-
❑Burial Date Cemetery or Crematory
September 29, 2011 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z El Removal and/or Held
and/or Address
a Hold Pine View Crematorium
0 Date Point of
0;❑Transportation Shipment
0 by Common Destination
O Carrier
❑ Disinterment Date Cemetery Address
Date Cemetery Address
Ell Reinterment
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
t Remains are Shipped, If Other than Above
• Address
CT Permission is h eby ranted to dispose of the human ains desc ibed ab ve as indicate .
Date Issue +// Registrar of Vital Statistic��
(sigriii)
District Numbe6>5 PlaceAlun t ��Ex.4
▪ I certify that the remains of the decedent identified above were disposed of in
accordance with this permit on:
W -Date of Disposition 10 lb Place of Disposition ALti to..) C.f lofivw—
(address)
W.
EC (section) (lot number) (grave number)
c` Name of Sexton or Pe n in Charge f Premises 4--,s4,,p,Ltr ce:01,911-
Z (ple`ase print)
W Signature Title Cs7e rno>9
(over)
DOH-1555 (02/2004)