Manning, Roberta NEW YORK STATE DEPARTMENT OF HEALTH ., _,,, /iC
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Roberta Lee Manning Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 14, 2015 78 War or Dates
1 Place of Death Hospital, Institution or
W City, Town or Village Fort Edward Street Address FORT HUDSON HEALTH CARE FAC.
CI W Manner of Death X❑ Natural Cause Accident 0 Homicide Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
111 Medical Certifier Name Title
CI Daniel C Larson M.D.,
Address
9 Carey Road Queensbury, NY 12804
Death Certificate Filed Di...t6Ngter Rc�lr Number
City, Town or Village ►►�� �
❑Burial Date Cemetery or Crematory
March 17, 2015 Pine View Crematorium
❑Entombment Address
', ®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
F. Hold Moss Street Cemetery
' Date Point of
❑a Transportation Shipment
0) by Common Destination
C i Carrier
Disinterment Date Cemetery Address
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
Remains are Shipped, If Other than Above
2 Address
>
W,'
0. Permission is ereby granted to dispose of the human re ins describ d above a indicated.
Date Issued (p Registrar of Vital Statistics Y,
_ (signet re)
District Number5'755 Place i Cr(A)it. .I V mil, ECI�
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 03/17/2015 Place of Disposition Quaker Road Queensbury,NY 12804
2 (address)
W Burial in Moss
CStsc Jr) A (lo_t number) J (grave number)
'' Name of Sexton or Person in Char a of Premises Aft �`'se print)
Signature � Title �'ived (over)
DOH-1555 (02/2004)