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Ulrich, Nancy NEW YORK STATE DEPARTMENT OF HEALTH .•* 41i. it g' Vital Records Section Burial - Transit Permit Name First Middle Last Sex Nancy Frederica Ulrich Female Date of Death Age If Veteran of U.S. Armed Forces, November 21, 2015 54 War or Dates IPlace of Death Hospital, Institution or W City, Town or Village Glens Falls Street Address Glens Falls Hospital W Manner of Death 0 Natural Cause 0 Accident El Homicide El Suicide n Undetermined r-i❑ Pending Circumstances Investigation W Medical Certifier Name Title Ci Marvin Davidowitz, M.D Address 100 Park Street Glens Falls, NY 12801 Death Certificate Filed District Number Register Nu,mber City, Town or Village 5601 L ❑ Burial Date Cemetery or Crematory November 24, 2015 Pine View Crematorium ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z ❑ Removal and/or Held y and/or Address Hold CO Date Point of riTransportation Shipment CO by Common Destination 3 Carrier Date Cemetery Address El 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 f Remains are Shipped, If Other than Above M Address W'i W Permission is re y granted to dispose of the human re 'ns desc ibed abo as indicat•d. Date Issue/ l Registrar of Vital Statistics "7— ,� /--lY 4 -2.i..._c_ � /'/ / (signature) District Number 5601 Place C4/-P�'S Ice , /i� /2€1/ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I- W Date of Disposition 11/24/2015 Place of Disposition Quaker Road Queensbury,NY 12804 2 (address) W CO (section) A (lot nu ber) (grave number) dName of Sexton or Person in Charge Premises G1n) 1. 4+1 Z 1 (please print) W Signature A Title ( III (over) DOH-1555 (02/2004)