Hubbard, Mary 1:3IW
NEW YORK STATE DEPARTMENT OF HEALTH "'
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Mary Ann Hubbard Female
Date of Death f,160,,. . Age If Veteran of U.S. Armed Forces,
27, 201 V 63 War or Dates
FPlace of Death Hospital, Institution or
W' City, Town or Village Glens Falls Street Address Glens Falls Hospital
WManner of Death 0 Natural Cause ❑ Accident E Homicide ❑ Suicide ❑Circumstanced ri es s nvestigation
C)
W Medical Certifier Name Title
Ch Frances Bollinger MD,
Address
161 Carey Rd Queensbury, NY 12804
Death Certificate Filed District Number r� / Register Number
J City, Town or Village 6C / 5 1--1
❑Burial Date Cemetery or Crematory
February 3, 2016 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
H Hold
(0 Date Point of
a. ❑Transportation Shipment
0) by Common Destination
Ci Carrier
Date Cemetery Address
El Disinterment
❑ 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
I— Remains are Shipped, If Other than Above
MAddress
W
C' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued a l . 1 X3 Registrar of Vital Statistics w C>� w
� I t (signature)
District Number ��� I Place 6(Q&"5 \ �� iv v`
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I-
W Date of Disposition 02/03/2016 Place of Disposition Quaker Road Queensbury,NY 12804 p;rx,yV,e' ckt,r,c,fc-rY
2 (address)
W
CO (section) (lot number) (grave number)
3
i0' Name of Sexton or Person in Charge of Premises J SvitY Stu,`c-is
z` (please print)
W Signature I Title Crr,ct1or
(over)
DOH-1555 (02/2004)