Asplund, Mercy NEW YORK STATE DEPARTMENT OF HEALTH ?S
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Mercy Park Asplund Female
Date of Death Age If Veteran of U.S. Armed Forces,
October 19, 2011 77 War or Dates
ZPlace of Death Hospital, Institution or
w City, Town or Village Hudson Falls Street Address 65 Pearl Street
W Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide 0 Suicide 1-1 Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
Joseph C. Mihindu, MD,
Address
20 Murray Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Sort F a.-1/S 5 7a(e IS
❑Burial Date Cemetery or Crematory
October 20, 2011
❑Entombment Address
®Cremation
Date Place Removed
z ri Removal and/or Held
O and/or Address
F. Hold
5 Date Point of
c 1-1
Li Transportation Shipment
0) by Common Destination
a Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
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';
131' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued /D ./. .. // Registrar of Vital Statistics ; per '. Q_
(signature)
District Number 57a le Place LA p/, a.t_,. / j -kQ i (j,
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z /�
i,hi Date of Disposition (0/Z-hi Place of Disposition P,.ititt,J C,i'e1*q{dr ve-
2 (address)
co
ce (section) (lot number) (grave number)
p; Name of Sexton or Person in arge of Pre ' es A,st Ltr Sta.{lt
C�� , � (please print)
W Signature t Title Cflt f6A i oft_
(over)
DOH-1555 (02/2004)