DePalo, Constance NEW YORK STATE DEPARTMENT OF HEALTH 5 'Z
Vital Records Section „ ; , Burial - Transit Permit
Name First Middle Last Sex
Constance DePalo Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 1, 2016 94 War or Dates
1 a e of Death Hospital, Institution or
W it , Town or Village Glens Falls Street Address Glens Falls Hospital
W' anner of DeathELI Natural Cause 0 Accident 0 Homicide 0 Suicide 0Undetermined ri Pending
Circumstances Investigation
WW Medical Certifier Name Title
CI Stephen Perazzelli, M.D
Address
100 Park Street Glens Falls, NY 12801
th Certificate Filed District Number Registe Number
t
Town or Village , e in 5 Fct t t s 5601 9.9'
❑Burial Date Cemetery or Crematory
December 2, 2016 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z Removal and/or Held
O and/or Address
F: Hold
a6 Date Point of
Transportation Shipment
0 by Common Destination
CI Carrier
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 Whom
I—„ Remains are Shipped, If Other than Above
Address
IX
Ili
CL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued j 2/Z J 2q i 6 Registrar of Vital Statistics l.3 C. , 4.w
(signature
District Number 5601 Place 4 (si.A,c co, 0S !U Y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1
uDate of Disposition 12/02/2016 Place of Disposition Quaker Road Queensbury,NY 12804
W (address)
CO
t (section) (lot number) (grave number)
aName of Sexton or Person in Charge of Pre ises (�r, br Sp.mit
z please print)
LU Signature r Asp Title ('.E41h1L
(over)
DOH-1555 (02/2004)