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Boisselle, Nina NEW YORK STATE DEPARTMENT OF HEALTH 1 32 Vital Records Section Burial - Transit ermit .{t°Y Name First Middle Last Sex 41 Nina Joan Boisselle Female Date of Death Age If Veteran of U.S. Armed Forces, June 25, 2011 78 War or Dates Place of Death Hospital, Institution or t f City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death r n ELI Natural Cause 0 Accident Homicide 0 Suicide ElUndetermined Pending Circumstances Investigation Medical Certifier Name Title r. David Foote Md, Address Rt 4 Hudson Falls, NY 12839 44 Death Certificate Filed District Number Registe Number City, Town or Village sj/ 0 Burial Date Cemetery or Crematory June 29, 2011 Pine View Crematorium ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Removal Date Place Removed El and/or Held 1-1 and/or Address Hold • Date Point of❑Transportation Shipment by Common Destination Carrier El Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home, Inc. 00276 �1 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 Address Permission is h reby granted to dispose of the human remains desc a ove mdic ,/4_._ Date Issued 6/02,08W Registrar of Vital Statistics �'�"� (signature) District Number ,560/ Place /e,iS ,f1.1 "/ /02J'0% �j I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 4-'30-11 Place of Disposition -OH t J C^tr*etcs'i+.... (address) (section) (lot number (grave number) Li s Name of Sexton or Pe n in Cha ge of Premises f"� . v.44- a- (please print) Signature Title a h litt- (over) DOH-1555 (02/2004)