Canary, Alida NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Trans t Permit
Name First Middle Last Sex
Alida Joan Canary Female
Date of Death Age If Veteran of U.S. Armed Forces,
April 10, 2016 54 War or Dates
i-- Place of Death Hospital, Institution or
WCity, Town or Village Hudson Falls Street Address 28 Poplar Street
Ca Manner of Death J Natural Cause Accident Homicide Suicide Undetermined Pending
IliU Circumstances Investigation
L Medical Certifier Name Title
Roland T. Phillips, M.D. Dr.
Address
6 Care Lane Saratoga Springs, NY 12866
Death Certificate Filed District Number Register Number
City, Town or Village S'7 a (o t ,`
❑Burial Date Cemetery or Crematory
April 12, 2016 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
zriRemoval and/or Held
}. and/or Address
1:: Hold
N Date Point of
Transportation Shipment
Cl) by Common Destination
C 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
H r Remains are Shipped, If Other than Above
2 Address
CC
W'«
M. Permission is hereby granted to dispose of the human remains M,cribed above as indicated.
Date Issued V- if /6 Registrar of Vital Statistics
(signature)
District Number 9 72h Place v
I certify that the remains of the decedent identified a ove were disposed of in accordance with this permit on:
W; Date of Disposition 04/12/2016 Place of Disposition Quaker Road Queensbury,NY 12804
W (address)
CO
Ce (section) di,(lot
number) (grave number)
0` Name of Sexton or Person in Charge Premises JgAnt/n
z /ease print)
W Signature G-2 Title (1?-F Ur92
(over)
DOH-1555 (02/2004)