Mayotte, Theresa INLVV IvRr\JI/1ICLJCrHKIIVItNVI Vt- 11tALI11 1 �"l" L I (;,
Vital Records Section :¢� --V-„ Burial - Transit ermit
Name First - Middle Last Sex
Theresa Margaret Mayotte Female
Date of Death Age If Veteran of U.S.Armed Forces,
March 23, 2015 93 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address
Manner of Death 0 Natural Cause ElAccident 0 Homicide ❑ Suicide EUndetermined Pending
Circumstances Investigation
Medical Certifier Name Title
alp
John E. Cunningham MD,
Address
90 South St. Glens Falls, NY 12801
in Death Certificate Filed DistrictIlumIDBI Register Number
City, Town or Village
❑Burial Date Cemetery or Crematory
❑Entombment Address
Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
I Removal and/or Held
and/or
. Address
:. Hold
Date Point of
Transportation I Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
14 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
Address
C,° Permission is ere granted to dispose of the human re iins4escr'bed bov as indic ed.
Date Issued Registrar of Vital Statistics Y i,
„....._____._, ,,f (signature)
District Number515 Place ) 0 LwaAd
V
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 03/30/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
71
(section) ,(dot number) (grave number)
Name of Sexton or Person in Charge 14 3r
of Premises f;�
(pie se print)
Signature I/ Title i "n ri
(over)
DOH-1555 (02/2004)