Valyer, Lillian NEW YORK STATE DEPARTMENT OF HEALTH re. it 1-7"
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
,• y. Lillian Anna Valyer Female
_3i=° Date of Death Age If Veteran of U.S. Armed Forces,
February 4, 2015 84 War or Dates
F Place of Death Hospital, Institution or
ICity, Town or Village Gansevoort Street Address 261A Brownville Rd.
-CI
Manner of Death Natural Cause ❑ Accident El Homicide ❑ Suicide ❑ Undetermined ❑ Pending
a Circumstances Investigation
F Medical Certifier Name Title
13 Kevin Dooley, M.D. Dr.
Address
7 135 North Road Wilton, NY 12831
• Death Certificate Filed, f `Q 1 District/Number Register tuber
City, Town or Village 1�1n Y-t1Th()MADLY13Ytic ' - t N O
❑Burial Date Cemetery or Crematory
February 5, 2015 Pine View Crematorium
❑Entombment
, Address
'� ®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
iii❑ Removal
and/or and/or Held
S Hold
Address
0 Date Point of
❑Transportation Shipment
by Common Destination
'i Carrier
;, Date Cemetery Address
❑ Disinterment
a Date Cemetery Address
Q Reinterment
Permit Issued to Registration Number
• Name of Funeral Home Carleton Funeral Home, Inc. 00281
4 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
E. Remains are Shipped, If Other than Above
Address
ir-
W=
d'° Permission is hereby ranted to dispose of the human r mains described above as indicated.
Registrar of Vital Statistics
;; Date Issued 9 �� 0,A.
(signature)
District Number t5[ Place .----------- V �r
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
uf Date of Disposition 02/05/2015 Place of Disposition Quaker Road Queensbury,NY 12804
a (address)
Cr (section) (lot number) (grave number)
CIName of Sexton or Person in Charg of Premises gr` ...cMeii'
/ ' (please print)
.- Signature Title Cgr►grc.
(over)
DOH-1555 (02/2004)