Waite, Mecleta Z—/ /
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section - :,. Burial - Transit Permit
Name First Middle Last Sex
Mecleta Elizabeth Waite Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 22, 2015 82 War or Dates
IPlace of Death Hospital, Institution or
w City, Town or Village Glens Falls Street Address Glens Falls Hospital
WL.
Manner of Death Natural Cause ❑ Accident El Homicide ❑ Suicide El Undetermined ❑ Pending
0 Circumstances Investigation
W Medical Certifier Name Title
3 Gamal Khalifa, M.D. Dr.
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village 5601 ) 59
❑Burial Date Cemetery or Crematory
March 23, 2015 Pine View Crematorium
t 2❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
ElRemoval and/or Held
o and/or Address
Hold Pine View Crematorium
Date Point ofil.
❑Transportation Shipment
by Common Destination
0 Carrier
Date Cemetery Address
El 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
I- Remains are Shipped, If Other than Above
z Address
w
5,1", Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 3 l23/f_5 Registrar of Vital Statistics j..."2"As/k\sa..-
(signature)
District Number 5601 Place 6 ( i -s ), l\s) of,
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
in Date of Disposition 03/4/2015 Place of Disposition Quaker Road Queensbury,NY 12804 ierit ti)14.11
2 (address)
w
CO
l'settlbHJ (lot number) (grave number)
a Name of Sexton or Person in Charge of Premises
Z' (please print)
LU Signature Title
(over)
DOH-1555 (02/2004)