Titchen, Edith NEW YORK STATE DEPARTMENT OF HEALTH . -_ R 77 711
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Edith Mae Titchen Female
= . Date of Death Age If Veteran of U.S.Armed Forces,
yam April 14, 2015 89 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address FORT HUDSON HEALTH CARE FAC.
• Manner of Death 0 Natural Cause ❑ Accident ❑Homicide El Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
' Philip Gara, M.D. Dr.
Address
Broadway Fort Edward, NY 12828
Death Certificate Filed District 7° Nu�r r,e�5 Registe �mber
City, Town or Village �
❑Burial Date Cemetery or Crematory
1 i kL ' I S Pine View Crematorium
• -❑Entombment
�� Address
®Cremation Quaker Road Queensbury,NY 12804
' Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
C; Date Point of
a. ❑Transportation Shipment
10, by Common Destination
; Carrier
ANNX
❑ Disinterment
Date Cemetery Address
El Reinterment Date Cemetery Address
ea
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
F- Remains are Shipped, If Other than Above
Z Address
X%
Permission is hereby granted to dispose of the human r ' s descri ed a ve a indicated.
Date Issued U-4(0—)5 Registrar of Vital Statistics
..-� f (signature)
District Number�7 Place / -1L (} T of -C,0011d
_ VVV
``*` I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
wDate of Disposition HI OIls Place of Disposition Quaker Road Queensbury,NY 12804
A1 (address)
f
(section) t� (lot number) (grave number)
01
i Name of Sexton or Person in Charge of Premises ry.,�,,p� if'f
z 1 (please print)
Signature ""v Titled "
(over)
DOH-1555 (02/2004)