Porlier, Clarissa -14
NEW YORK STATE DEPARTMENT OF HEALTH T 1 3�-�--
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Clarissa Lyn Porlier Female
Date of Death Age If Veteran of U.S. Armed Forces,
July 13, 2011 19 War or Dates
��. Place of Death Hospital, Institution or
w City, Town or Village Street Address 4383 State Route 29
Manner of Death❑ Natural Cause Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
U Circumstances Investigation
W] Medical Certifier Name Title
Michael Sikirica MD,
Address
50 Broad Street Waterford, NY 12188
Death Certificate Filed District Number Register Number
City, Town or Village
❑Burial Date Cemetery or Crematory
July 20, 2011 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
O and/or Address
p Hold
Date Point of
0. ❑Transportation Shipment
CO'' by Common Destination
a Carrier
Date Cemetery Address
❑ Disinterment
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00276
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
Remains are Shipped, If Other than Above
2 Address
a Permission is hereby granted to dispose of the human re ains described above as Inds ated.
-�-
Date IssuedE),7-/$ Registrar of Vital Statistics 0�-t-1-v C
(signature)
District Number 6 7414 Place` [ - `-V) 3 t
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
wDate of Disposition ")-21- k. Place of Disposition Ptnr`V to Crrrt-c if<<^-
(address)
W
(.0
(section) Ity (lot number)c (grave number)
aName of Sexton or Per n in Charge o Premises l Vtt`��� � `� ""�(1'
L. I(plle„ase print)
Signature Title at, wtrv�C
(over)
DOH-1555 (02/2004)