Graves, Katherine NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
77
Name First Middle Last Sex
Katherine Jo/ce GRAVES female
Date of Death Age If Veteran of U.S. Armed Forces,
K Jul 11 . 2016 War or Dates _0_
k Place of Death Hospital, Institution or
tit City,xT VIMik Glens Falls Street Address glens Fall s Hospi tat
Manner of Deat}0 Natural Cause ❑ Accident Ej Homicide El Suicide Undetermined El Pending
IU
01 Circumstances Investigation
U' Medical Certifier Name Title
Farhana Kamel. MD
0 Address
k4 Glens Palls Hospit-al
3* Death Certificate Filed District Number Register Number
AS Csi4(444/1)4010419P Glens Falls 5601 3 5 c
❑Burial Date Cemetery or Crematory
July 12, 2016 Pine View Crematorium
A
DE.zitombment Address
❑Cremation Tn of Queensbury, NY
Date
Place Removed
Removal and/or Held
E and/or Address
Hold
07
tt Date Point of
o_0 Transportation Shipment
0 by Common Destination
Carrier
Disinterment
Date Cemetery Address
❑ Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Carleton Funeral Home, Inc.
Name of Funeral Home 00281
e Address
.. 68 Main St. , Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
W1
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued Al j t z-j /{, Registrar of Vital Statistics L,3 QrwYv.ii `
Ah
(signature)
District Number 5601 Place City of Glens Falls, NY
-''4 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 11 13(IL Place of Disposition Pint °--, � o.,_
W (address)
1a,
0 (section) (lot numb ) (grave number)
z -tomref Name of Sexton or Person in Charg of Premises 4i1,1„
�z /�' (please print)
Ui Signature �` Title 4Te'itr<
(over)
DOH-1555 (02/2004)