Tucker, Shirley NEW YORK STATE DEPARTMENT OF HEALTH ,I , i 9s
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
o .
Shirley Laverne Tucker Female
Date of Death Age If Veteran of U.S. Armed Forces,
February 10, 2015 85 War or Dates
ZPlace of Death Hospital, Institution or
w City, Town or Village Argyle Street Address Washington Center
CL Manner of Death X❑ Natural Cause 0 Accident ❑Homicide ❑ Suicide ❑ Undetermined ❑ Pending
111
Circumstances Investigation
W Medical Certifier Name Title
Jennifer Hayes, M.D
Address
17 Madison St. Granville, NY 12832
Death Certificate Filed District Number Register Number
its' City, Town or Village -S )5 0 / 1
Date Cemetery or Crematory
El Burial February 13, 2015 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
„, Hold
140 Date Point of
0 Transportation Shipment
ta by Common Destination
c: Carrier
Date Cemetery Address
❑ Disinterment
❑ 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
t Remains are Shipped, If Other than Above
Address
Tit'
L . Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 0I/3laolS Registrar of Vital Statistics � ��o Qp�,, UV1Cr-v‘4147r)
- (signature)
District Number S1,5b Place r jp 1
"3 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
. Date of Disposition 02/13/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
1' ,
N (section) lot number) (grave number)
Name of Sexton or Perso in Char of Premises 1,llea �o
(p1 ase print)
W Signature ^' Title 112`''effi9
(over)
DOH-1555 (02/2004)