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Holley, Freda ,r., NEW YORK STATE DEPARTMENT OF HEALTH 3/, Vital Records Section Burial - Transit Permit Name First Middle Last Sex Freda Holley Female Date of Death Age If Veteran of U.S. Armed Forces, April 21, 2016 99 War or Dates 1- - c- of Death Hospital, Institution or Wity, own or Village Glens Falls Street Address Glens Falls Hospital anner of Death Fri.i Natural Cause El Accident 0 Homicide El Suicide 0 Undetermined Pending 11,1 0Circumstances Investigation W Medical Certifier Name Title 0 Frances Bollinger MD, Address 161 Carey Rd Queensbury, NY 12804 eCertificate Filed District Number Register Number Cit Town or Village t,(e 5 I-c 1 I S 5601 Z), G ❑Burial Date Cemetery or Crematory Pine Vew Crematorium ❑Entombment Address ©Cremation Queensbury,NY 12804 Date Place Removed z El Removal and/or Held ▪ and/or Address Hold 0 Date Point of irl. El Transportation Shipment CO by Common Destination CI Carrier Disinterment Date Cemetery Address 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 1-, Remains are Shipped, If Other than Above ' Address CE W' Ct. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued Lj /Z 2 i6 Registrar of Vital Statistics t✓)r,"�,,,_g_ W�� (signa ure) District Number 5601 Place 6 (s2AvNS S i S ni Li I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition gitif t , Place of Disposition Queensbury,NY 12804 (address) Ui (11 (section) /y (lot number) (grave number) a. Name of Sexton or Person in Charge of Premises /10 -S 0 Z flJ easepT* t) Ill Signature v"l. i Title attlIgnik (over) DOH-1555 (02/2004)