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Waters, Sandra 3 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Se tior_,I Burial - Transit Permit Name First Middle Last Sex Sandra Elaine Waters Female Date of Death Age If Veteran of U.S. Armed Forces, December 31, 2015 74 War or Dates wPlace of Death Hospital, Institution or City, Town or Village Glens Falls Street Address 43 Ridge Street, Apt 602 W Manner of Deathrrl LI Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending Ci Circumstances Investigation WW Medical Certifier Name Title 0 Thomas Coppens, M.D. Dr. Address Three Irongate Center Glens Falls, NY 12801 Death Certificate Filed District Number Register Nu�r City, Town or Village 5601 U3 0 Burial Date Cemetery or Crematory January 4, 2016 Pine View Crematorium ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed ElRemoval and/or Held and/or Address Hold NORTH GRANVILLE O; Date Point of CEMETERY a ❑Transportation Shipment U? by Common Destination a 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 2 Address aC W a Permission is hereby granted to dispose of the human remains described above indicated. Date Issued it 1---) 1 I b Registrar of Vital Statistics W C..,'v-N,-RArCj _AOC- (signature) District Number 5607 Place 6 �SUv-S toy ,\_s f tk) 7 12-901 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: F- j -�-/jam YMQ.Lli e.w // W Date of Disposition al 6 Place of Disposition Quaker Road Queensbury,NY W804 2 (address) W co rt (section) ll (lot number) (grave number) dName of Sexton or erson i Charge of Premises J L. rt [,1ra .c.ri A Z (please print) W' Signature 4------ Title CCre .0 a,/ (over) DOH-1555 (02/2004)