Barth-Nelson, Patricia •
NEW YORK STATE DEPARTMENT -ALTH t
Vital Records Section Burial - Transit Pgrmit
Name First Middle Last I Sex
Patricia Lynn Barth-Nelson Female
Date of Death Age If Veteran of U.S.Armed Forces,
March 10, 2011 62 War or Dates
Place of Death Hospital, Institution or
a1' City, Town or Village Glens Falls Street Address Glens Falls Hospital
CI Manner of Death X❑ Natural Cause El Accident ❑ Homicide ❑ Suicide El Undetermined ❑ Pending
LU Circumstances Investigation
t
W' Medical Certifier Name Title
i Nancy Carney, MD,
Address
Warrensburg Health Center Warrensburg, NY 12885
y Death Certificate Filed District Number I Reg ter umber
,W
City, Town or Village 5601 a
❑Burial
Date Cemetery or Crematory
March 16, 2011 Pine View Crematorium
❑Entombment
Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
zi
❑ Removal and/or Held
0 and/or Address
H' Hold
Date Point of
Transportation Shipment
CO` by Common Destination
1'' Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Reinterment
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
I— Remains are Shipped, If Other than Above
Address
IX
W:
Permission is here y ranted to dispose of the human remains describ dab ve in�
Date Issued D3/ 2011 Registrar of Vital Statistics �_
/` (signature)
District Number 5601 Place /GGz-v Al/ _ /L>7
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition 3-It-i I Place of Disposition Ptia U"et) C.c.-.(e
2 (address)
Wce'
(section) (lot number) (grave number)
j" Name of Sexton o rson( nCharemises iA f`stufitir &ikatt
Z.' (please print)
tit Signature Title ��EM' `
(over)
DOH-1555 (02/2004)