Hart, Magdelena NEW YORK STATE DEPARTMENT OF HEALTH
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Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Magdalena Maria Hart Female
Date of Death Age If Veteran of U.S. Armed Forces,
November 9, 2016 55 War or Dates
} Place of Death Hospital, Institution or
W' City, Town or Village Hudson Falls Street Address 38 Willow Street
CI Manner of Death LaiNatural Cause El Accident El Homicide E Suicide ri Undetermined ri Pending
Circumstances Investigation
W Medical Certifier Name Title
U
Patricia Auer,
Address
Queensbury Hudson Headwaters Queensbury, NY 12804
1 Death Certificate Filed District Number Register Number
City, Town or Village 5 7 a b a 7
Z. ❑Burial Date Cemetery or Crematory
November 14, 2016 Pine View Crematorium
❑Entombment Address
i-®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
k � Removal and/or Held
and/or Address
gi� Hold
Date Point of
aEl Transportation Shipment
Ci')+ by Common Destination
Carrier
'' Disinterment Date Cemetery Address
❑ Reinterment
Date Cemetery Address
IV Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
_ Address
E , Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
:gin, :
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
IX
W
[ . Permission is hereby granted to dispose of the human remains escribed above as indicated.
4,12' Date Issued i/ / d- e ! Registrar of Vital Statistics Qp�L4 �_(signature)
District Number.-7,?� Place �..L J L a. .� T c lSL ,
I certify that the remains of the decedent identified aboL were disposed of in accordance with this permit on:
W Date of Disposition 11/14/2016 Place of Disposition Quaker Road Queensbury,NY 12804
W; (address)
CO
rt= (section) l (lot number) (grave number)
Q Name of Sexton or Person in Charge f Premises ('hnk✓' Sr.siittt
Z ( lease print)
W Signature C t Title r' tm►i7btt
(over)
DOH-1555 (02/2004)