Hughes, Mary NEW YORK STATE DEPARTMENT OF HEALTH # -L%`l
Vital Records Section
' Burial - Transit Permit
Name First Middle Last Sex
Mary Hirrrett Hughes Female
Date of Death Age If Veteran of U.S. Armed Forces,
September 16, 2012 93 _ War or Dates
Place of Death Hospital, Institution or
w City, Town or Village Fort Edward Street Address FORT HUDSON HEALTH CARE FAC.
C] Manner of Death LI Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
W Circumstances Investigation
W Medical Certifier Name Title
0 Philip Gara, M.D. Dr.
Address
Broadway Fort Edward, NY 12828
Death Certificate Filed District Number Register umber
City, Town or Village .J��� ��p
❑Burial Date Cemetery or Crematory
September 19, 2012
❑Entombment Address
®Cremation
Date Place Removed
z ❑ Removal and/or Held
and/or Address
E_` Hold Pine View Crematorium
C Date Point of
it ❑Transportation Shipment
(/) by Common Destination
E Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
Li 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
Remains are Shipped, If Other than Above
2 Address
W
L1 Permission is h eb ranted to dispose of the human ains describ above s indicated.
Date Issue / Registrar of Vital Statisti
(signature
District Numbe575c Place /tom ( t C
I— I certify that the remains of the decedent identified above were disposed of in
accordance with this permit on:
WDate of Disposition '1 110117L Place of Disposition 2:n.t V`wJ Ciro--to f a vim,
2 (address)
W
CO
(section) A pat number) (grave number)
C' Name of Sexton or Pers n in Charge of P mises (i) �`-- �v44
14-
Z (pi print)
LU Signature Title CV lvi ll-TO a--
(over)
DOH-1555 (02/2004)