Chiriboga, Ximena NEW YORK STATE DEPARTMENT OF HEALTH Y
Vital Records Section Burial - Transit-Permit
' Name First Middle Last Sex
Ximena Chiriboga Female
Date of Death Age If Veteran of U.S. Armed Forces,
October 23, 2011 75 War or Dates
2 Place of Death Hospital, Institution or
w City, Town or Village Saratoga Springs Street Address Saratoga Hospital
CI Manner of Death❑ Natural Cause ❑ Accident ❑ Homicide ❑ Suicide n Undetermined ri❑ Pending
LI Circumstances Investigation
W Medical Certifier Name Title
CI
Address
Death Certificate Filed District Number 1 /6// Register Number__
City, Town or Village 7 `./,) R
❑Burial Date Cemetery or Crematory
October 27, 2011 Pine View Crematorium
❑Entombment Address
®Cremation _ Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
1. Hold
N Date Point of
p. ❑Transportation Shipment
O by Common Destination
CI Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Reinterment
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
t, Remains are Shipped, If Other than Above
2 Address
W
a' Permission is hereby granted to dispose of the human remains d cribe a ve as dis ated.
Date Issued %O�p'��Q/7 Registrar of Vital Statistics ,�,( „ilk
(signature)
District Number C ,j Q/ Place SARATOGA SPRINGS
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition 1011111 Place of Disposition ..1):r41L ) e�r*<fdr,,A.,
(address)
W:
InOt (section) A (lot numb (grave number)
ciName of Sexton or Person in arge of Pre ises 4(.4 stØJr t-4 fi-
Z 7 (please print)
• Signatu
re ure Title CR eW�'�1<.YL
c
Y
(over)
DOH-1555 (02/2004)