Houghton, Eleanor ff'
NEW YORK STATE DEPARTMENT OF HEALTH i 1 651
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Eleanor Louise Houghton Female
Date of Death Age If Veteran of U.S. Armed Forces,
September 13, 2016 90 War or Dates
F lac of Death Hospital, Institution or
w City Town or Village Glens Falls Street Address Glens Falls Hospital
anner of Death mIL.j Natural Cause ❑ Accident ElHomicide ❑ Suicide ❑ Undetermined ri❑ Pending
Investigation
U
W Medical Certifier Name Title
G`1 Suzanne M. Rayeski, M.D
Address
170 Warren Street Glens Falls, NY 12801
h Certificate Filed District Number
��" Register Number
i )Town or Village (e S F & ( (S ,CoO) L��`/
1
Burial Date Cemetery or Crematory
September 15, 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
( Date Point of
uu- ❑Transportation Shipment
0 by Common Destination
p Carrier
Date Cemetery Address
El Disinterment
Date Cemetery Address
❑ 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
1-- Remains are Shipped, If Other than Above
2 Address
fE
W
p. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 9 ) i S / (� Registrar of Vital Statistics 3 -y-�� v Q
(signature)
District Number £b0 f Place 6 C.QA,S 6 \ \ S, A)
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 09/15/2016 Place of Disposition Quaker Road Queensbury,NY 12804
2 (address)
W
CO
Ce (section) /�� (lot number) (grave number)
0
01 Name of Sexton or Person in Charge of Premises C�rCf. in/ ,S h"
z ,(please print)
W Signature c� r� Title ceu= ik,
(over)
DOH-1555 (02/2004)