Perry, Barbara NEW YORK STATE DEPARTMENT OF HEALTH , :[ ��
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Barbara Ann Perry Female
Date of Death Age If Veteran of U.S. Armed Forces,
June 18, 2015 49 War or Dates
I Place of Death Hospital, Institution or
ui City, Town or Village Queensbury Street Address 68 Boulevard
Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined El❑ Pending
LU
U Circumstances Investigation
W Medical Certifier Name Title
C] Ageel Gillani, M.D. Dr.
Address
100 Park Street, Pryne Pavillian Glens Falls, NY 12801
Death Certificate Filed District Nu nber Register Number
City, Town or Village )(A'}f ((YJ
❑Burial Date Cemetery or Crematory
June 19, 2015 Pine Vew Crematorium
❑Entombment Address
®Cremation Queensbury,NY 12804
Date Place Removed
z n Removal and/or Held
I ' and/or Address
p. Hold GLENS FALLS CEMETERY
Date Point of
❑Transportation Shipment
by Common Destination
CI Carrier
Date Cemetery Address
II: Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. 0. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
F- Remains are Shipped, If Other than Above
• Address
CC
C' Permission is hereby granted to dispose of the human rem ' s e cubed a •ica •.
Date Issued L .(9,c,1,6*-- Registrar of Vital Statistics a . i
(signature)
District Number Place /(p e-u-ibiiAr'1 ,
I certify that the remains of the decedent identified alp. : were disposed of i- accor•&=nce with this permit on:
W Date of Disposition 06/19/2015 Place of Disposition Queensbury,NY 1
2 (address)
W.;'
tO
section) J (�, (lot number) (grave number)
O Name of Sexton or P rson 'n Ch a of Premises .k''h a T�' 1� - /1‹
Z ._.._-- "', (please print)
Signature Title (or"'1 c')day
1,41
(over)
DOH-1555 (02/2004)