Nassivera, Joan NEW YORK STATE DEPARTMENT OF HEALTH L3
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Joan Mary Nassivera Female
"7 Date of Death Age If Veteran of U.S. Armed Forces,
December 25, 2011 68 War or Dates
Place of Death Hospital, Institution or
Llia City, Town or Village Fort Ann Street Address 338 Hadlock Pond Road
Manner of Death 0 Natural Cause ❑ Accident ❑Homicide ❑ Suicide ❑ Undetermined El Pending
0 Circumstances Investigation
tilt:: Medical Certifier __,Name Title
Address& (c i 6
Death C-rtor Vill Filed o1 // i Dist Number RegisterrAlumber
112 City ow- or Village U (,f .� '/. - `7
❑Burial Date Cemetery or Crematory
December 27, 2011 Pine View Crematorium
❑Entombment Address
7 ` ®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
O and/or Address
Hold
' Date Point of
cci. ❑Transportation Shipment
`070 by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
" ❑ Reinterment Date Cemetery Address
,x
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
Remains are Shipped, If Other than Above
2 Address
wIL..............
Permission is hereby granted to dispose of the human r ins described above a. ndi .ted.
, Date Issued , . �-Q9/C Registrar of Vital Statistics ,; ,,, >��/je4� ;7�,p (,,
(signature)
District Numbe67S-9 Place (e -,erg ' 7 2r.2-`7
H' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I
W; Date of Disposition tX-�1,-.)01 Place of Disposition Perie u,a,e ,, Cr-c,o-id-or,ru rat
2 t 2 (address)
t (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises t 4rkA-I. �•t le
�^ � �� y (please print)
W Signature �.�'rr�'7' -�+�.�'L Title U'`��ory A '1...'
(over)
DOH-1555 (02/2004)