Loading...
Derusha, Clara NEW YORK STATE DEPARTMENT OF HEALTH 6g Vital Records Section Burial- Transit Permit Name First Middle Last Sex Clara Derusha Female Date of Death Age If Veteran of U.S. Armed Forces, June 19, 2016 (` War or Dates FE Place of Death Hospital, Institution or W City, Town or Village Glens Falls Street Address Glens Falls Hospital ❑ Manner of Death X❑Natural Cause 0 Accident � Homicide 0 Suicide Undetermined Pending W Circumstances Investigation 0 W Medical Certifier Name Title ❑` J. Michael Helligan, PAN- . Address 200 Broad Street Schu r�lerville, NY 12871 Death Certificate Filed District Number Register Number City, Town or Village 6 6 1 ? j ❑Burial Date Cemetery or Crematory June 27, 2016 Pine Vew Crematorium ❑Entombment Address ©Cremation Queensbury,NY 12804 Date Place Removed Removal and/or Held C and/or Address i Hold CO' Date Point of 0 0 Transportation Shipment (I) by Common Destination ❑ Carrier 111 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 WhomI— Remains are Shipped, If Other than Above Address Ce W' n. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued b t 'z} 1 1,6Registrar of Vital Statistics G L �(g � am.nature) District Number 5 60 I Place C 5' 4 ( Ns , N `T —' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W' Date of Disposition 06/27/2016 Place of Disposition Queensbury,NY 12804 (address) W'1 0) a (section) (lot number) r. (grave number) 0, Name of Sexton or Person in Charge of remises iioi St.T ' z (please print) ,e W Signature �"� Title (over) DOH-1555 (02/2004)