O'Hare, Alice (z.) i
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Alice Mary O'Hare Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 20, 2011 83 War or Dates
Place of Death Hospital, Institution or
uj City, Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death m Natural Cause IIIAccident ElHomicide L. Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
WW Medical Certifier Name Title
Ca Mathew Varughese, MD Dr.
Address
Glens Falls Hospital Hudson Falls, NY 12839
Death Certificate Filed District Number Register Number
City, Town or Village 5601 _C c
❑Burial Date Cemetery or Crematory
December 27, 2011 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
Hold
( Date Point of
❑Transportation Shipment
0 by Common Destination
Q Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
El 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
I— Remains are Shipped, If Other than Above
2 Address
W
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12 I Z 2/i I Registrar of Vital Statistics U &)C Z
i (signature)
District Number 5601 Place 6 (s2),-5 Fc l , s2 OJ l.f/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Il—.
WDate of Disposition()-3o-43i( Place of Disposition 'Roe U i et,o crer►1cetor:',0 y✓x
X (address)
W
1X (section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises I '9'Wlo+LY 1 ru telk
�� (please print)i
Signature �,rw i�Y�4'i
Title Crcwicc ory Vr%1
(over)
DOH-1555 (02/2004)