McDowell, Harriet NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section , a li Burial - Transit Permit
Name First Middle Last Sex
Harriet Alice McDowell Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 8, 2011 85 War or Dates
ZPlace of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide El Suicide ❑ Undetermined ❑ Pending
U Circumstances Investigation
W Medical Certifier Name Title W
Robert W Sponzo MD,
Address
102 Park St. Glens Falls, NY 12801
Death Certificate Filed District N3 1 Regpe u er
City, Town or Village
❑Burial Date Cemetery or Crematory
December 9, 2011 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
h. Hold Union Cemetery
CO Date Point of
d ❑Transportation Shipment
t/) by Common Destination
CI Carrier
❑ Disinterment Date Cemetery Address
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
1— Remains are Shipped, If Other than Above
▪ Address
w
CL Permission is hereby granted to dispose of the human remains descri e ab ve ind' e .
Date IssuedO `2d// Registrar of Vital Statistics _/"
J / (signature)
District Number ��/ Place 6/el-,o //h1 if)y
• I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition a- 12-1®N Place of Disposition ptiel-C U i C VA> CV-erric,...40r-:.)ral
2 (address)
Ui
(section) '� (lot number) (grave number)
Name SextonPerson in Charg of Premises t t. i1-e L��
Z of or Trno'
(please print)
L .�i�
U- Signature 134-- Title Cr-e-t-.n°4y-i 14554.
(over)
DOH-1555 (02/2004)