Sherman, Irene NEW YORK STATE DEPARTMENT OF HEALTH ' " lit g ��
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Vital Records Section Burial - Transit Permit
1 Name First Middle Last Sex
Irene Edith Sherman Female
Date of Death Age If Veteran of U.S. Armed Forces,
November 29, 2015 83 War or Dates
ZPlace of Death Hospital, Institution or
W City, Town or Village Granville Street Address The Orchard
❑ Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
W Circumstances Investigation
W Medical Certifier Name Title
in Jennifer Hayes, M.D
Address
17 Madison St. Granville, NY 12832
Death ertificate Filed District Number Register Number
City, Tow5or Village G'(Z41•1VI(-IX �756 3 g
❑Burial Date Cemetery or Crematory
December 1, 2015 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
F- Hold
N Date Point of
, j I I Transportation Shipment
U) by Common Destination
5 Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
El 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
I— Remains are Shipped, If Other than Above
M Address
Ce
CL Permission is hereby
+ granted to dispose of the human remains described above as indicated.
Date Issued 1)40/La01 S Registrar of Vital Statistics 912--n-vil
4 i G�
(signet re)
District Number 5-7S6 Place -rpwN c G-f2,4N1111.4.6-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W' Date of Disposition 12/01/2015 Place of Disposition Quaker Road Queensbury,NY 12804
MI' (address)
W
W (section) (lot number) (grave number)
( Name of Sexton or Person in Char of Premises A0
❑ (please print)
U-I Signature Title f 4 z(1
(over)
DOH-1555 (02/2004)