Martin, Diane NEW YORK STATE DEPARTMENT OF HEALTH, fi •i P. l'ic
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Diane Martin ,,, Female
Date of Death Age If Veteran of U.S. Armed Forces,
November 12, 2015 71 War or Dates
I— Place of Death Hospital, Institution or
W: City, Town or Village Milton Street Address Gateway House of Peace
Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
0 Aqeel A. Gillani, M.D. Dr.
Address
102 Park St Glens Falls, NY 12801
Death Certificate Filed District Number 1 Register Number
City, Town or Village
❑Burial Date Cemetery or Crematory
November 16, 2015 Pine View Crematorium
❑Entombment Address
®Cremation Tn of Saratoga,NY
Date Place Removed
z ❑ Removal and/or Held
and/or Address
p Hold SARATOGA NATIONAL
01. Date Point of CEMETERY
❑Transportation Shipment
0 by Common Destination
0; Carrier
' El Disinterment Date Cemetery Address
Date Cemetery Address
El Reinterment
Permit Issued to Registration Number
_1 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
• Address
W
�' Permission is h reby granted to dispose of the hum• ' , a ‘s de be. ._ bove as' iica
Date Issued 1 1 Up 15
Registrar of Vital Statis qcs i, , _l
(( (signature)
District Number I Place ` �
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 11/16/2015 Place of Disposition Tn of Saratoga,NY
2 (address)
W
co
c (section) 4(lot number) (grave number)
• Name of Sexton or Person in Charge of remises 1 St 4 f
zX (par se print)
W Signature Title r "rYrt
(over)
DOH-1555 (02/2004)