Plue, Cynthia NEW YORK STATE DEPARTMENT OF HEALTH "r' ` '` 30
Vital Records Section Burial - Transit Permit
" Name First Middle Last Sex
C nthia Jean Plue Female
Date of Death Age If Veteran of U.S.Armed Forces,
NO Ma 15, 2015 58 War or Dates
P - of Death Hospital, Institution or
Ci own or Village Glens Falls Street Address Glens Falls Hospital
- ner of Death uu Natural Cause ❑ Accident ❑Homicide 0 Suicide ❑ Undetermined El❑ Pending
Circumstances Investigation
0.41 Medical Certifier Name Title
GAMAL G KHALIFA, M.D.,
: e Address
Death Certificate Filed District Number Register Number
E i own or Village oIP,.S 'CA(/j 5601 c,J 7
urial Date Cemetery or Crematory
May 20, 2015 Pine View Crematorium
A ❑Entombment
` Address
(®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
v
❑ Removal and/or Held
and/or Address
_ Hold
0 Date Point of
iv❑Transportation Shipment
by Common Destination
Carrier
0 Disinterment Date Cemetery Address
c 0 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
txAddress
Wf
ar
Permission is hereby granted to dispose of the human remains des i e ab e a mated.
,S Registrar of Vital Statistics
` Date Issued O �/Kj�?O� 9� ��
_ (signature)
District Number 5601 Place �� ��
:° I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 05/20/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
Ce (section) ,� (lot number) (grave number)
aName of Sexton or Person incharge of Premises zt�.
' (please print)
'W Signature i /� Title lRF.040,�
(over)
DOH-1555 (02/2004)