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Purdy, Maria NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transi Permit e. Name First Middle Last Sex Maria Purdy Female Date of Death Age If Veteran of U.S. Armed Forces, 44, February 8, 2011 99 War or Dates Place of Death Hospital, Institution or fri City, Town or Village Fort Edward Street Address FORT HUDSON HEALTH CARE FAC. Manner of Death m.i Natural Cause ❑ Accident ❑ Homicide ❑ Suicide n Undetermined ❑ Pending Circumstances Investigation Medical Certifier Name Title Roslyn Socn1 of N➢n Address 2 Broad St. Plaza Glens Falls, NY 12801 Death Certificate Filed District Number Regis1 r}lumber ' City, Town or Village S7 5 j �' ry or Crematory Date Cemetery February 1452011 Pine View Crematorium ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 s• Removal Date Place Removed ❑ and/or Held • and/or Address Hold Date Point of 0 Transportation Shipment by Common Destination Carrier I ❑ Disinterment Date Cemetery Address ❑ Reinterment Date Cemetery Address Permit Issued to Registration Number �. Name of Funeral Home Carleton Funeral Home, Inc. 00276 ?m, Address fin Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above 1: Address 4 'm Permission is h reb granted to dispose of the human ins described above a indicated. Date Issue Registrar of Vital Statisti i., //%' 2 ? (si ature) District Numbe 75 Place ca..) I certify that the remains of the decedent identified a e were disposed of in accordance with this permit on: Date of Disposition 02/15/2011 Place of Disposition Quaker Road Queensbury,NY 12804 (address) (section) , , (lot ber) (grave number) Name of Sexton or Person in Charg of Premises t�q t�s � c� (please print) • `' Signature I Title Cae fir► +vfi- (over) DOH-1555 (02/2004)