Cameron, Margaret NEW YORK STATE DEPARTMENT OF HEALTH 11 1SL
Vital Records Section _ . -tir Burial - Transit Permit
Name First . :'dle Last Sex
Margaret Pauline _ Cameron Female
Date of Death Age If Veteran of U.S. Armed Forces,
September 9, 2011 87 War or Dates
I— Plac- •'geath / Hospital, Instituti or J �/�
W
City Town or Village/ '/ � o Ay Street Address/ , /J1siv)// 5,4 7 /164.49
W' Man = Death• X❑ Natural Cause n Accident 0 Homicide 0 Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
0 Nowa Siddiqui, M.D. Dr.
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Nu er Register tuber
City, Town or Village 4-7-
❑Burial Date Cemetery or Crematory
September 12, 2011 Pine View Crematorium
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z Removal and/or Held
and/or Address
F- Hold
5 Date Point of
eL 0 Transportation Shipment
CO by Common Destination
0 Carrier
EilDisinterment 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
• Address
Ce
Ui
tl. Permission is h eby ranted to dispose of the human r ains described ove s indicated.
1 d Registrar of Vital Statistic �� t�
Date Issue //
--- (signature)
District Numbers�s Place /a_jh ccaZ4,/_
I certify that the remains of the decedent identified ab ve were disposed of in accordancec with this permit on:
W Date of Disposition 1 lit -lit Place of Disposition � w C U. {O f ttr•
2. (address)
LU CO_ (section) 71 (lot number) c (grave number)
O Name of Sexton or Pers in Charge of remises c'SA r S,h
� (p ase print)
Signature Title
W z
1- CR liN pSLOi-
(over)
DOH-1555 (02/2004)