Millington, Journee NEW YORK STATE DEPARTMENT OF HEALTH A
Vital Records Section Burial - Transit Permit`'4
Name First Middle Last Sex
Join-tie? Kayleeanna Rose Millington female
- Date of Death Age If Veteran of U.S. Armed Forces,
Dec 14, 2011 0 War or Dates _0_
Place of Death Hospital, Institution or
tit City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Li Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
LEJ
Circumstances Investigation
W Medical Certifier Name Title
0
Douglas Prevost MD
Douglas P dressSL, M:
Glens Falls, NY
it
- Death Certificate Filed g
District Number01 Register Number
City, Town or Village
Glens Falls
� 3.
Date CemeteryCr mato
El Burial Dec 16, 2011 or sineryView Crematorium
❑Entombment Address
�'cremation Queensbury, NY
Date Place Removed
z ❑ Removal and/or Held
and/or Address
Hold
Date Point of
Transportation Shipment
!f3 by Common Destination
Ci Carrier
ElDisinterment Date Cemetery Address
" ❑ Reinterment Date Cemetery Address
- Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 5501
•
- Address
P.O. Box 67, 68 Main St. , Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
h' Remains are Shipped, If Other than Above
2' Address
W
Ct., Permission is hereby granted to dispose of the human remains described above as indicated.
▪.,, Date Issued t 2/t 5/if Registrar of Vital Statistics kiJ c,.,"41,t„ Vi."-11-144"'
(signature)
i District Number 5601 Place Glens Falls, NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 0.-t(,-).r,t( Place of Disposition pco,0:.e;.J Cr-evne t4,-,,vwl,
2 (address)
Ili
,. (section) //(lot number) (grave number)
g' Name of Sexton or Person in Cha ge of Premises I t'v►r,t, y I.-1..e
` —^ (please print)
Signature dti�, 4 .. Title C'Tewno,`�ot7 14 .
(over)
DOH-1555 (02/2004)