Ryan, Marilyn NEW YORK STATE DEPARTMENT OF HEALTH t `► , 1 197
Vital Records Section Burial - Transit Permit
m Name First Middle Last Sex
Marilyn� Ryan Female
Date of Death Age If Veteran of U.S.Armed Forces,
July 5, 2015 Y3 War or Dates
""` Place of Deat Hospital, Institution or
W: City, Town o illag Hudson Falls Street Address 76 William Street
a Manner of Dea . Natural Cause El Accident 0 Homicide El Suicide ElUndetermined ri Pending
tif
- = Circumstances Investigation
Ui Medical Certifier Name Title
,a Robert L Evans DO,
Address
1 lrongate Center Glens Falls, NY 12801
Death Certific District Number Register Number
City, Town o Vilage�u,d5&c l--c�St,ks 3"�c /_,p 9.
,,0 Burial Date Cemetery or Crematory
July 7, 2015 Pine View Crematorium
f 0 Entombment Address
• ®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
Removal
and/or and/or Held
Hold
Address
Date Point of
-. Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
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
q Remains are Shipped, If Other than Above
_X`- Address
6
'" Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 7— 6_- a-0/3- Registrar of Vital Statistics a ` tea
(signature)
District Number 6- ))- Place I/,11'V_t 6 f /- 61 S ak E4 /ls
y
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
t Date of Disposition 07/07/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
1a
C;
I (section) (lot number) (grave number)
` - Name of Sexton or Person in Charge of Premises �IrC ��G+^ ''
__ (please print)
l Signature �'� Titled ,
4-1
(over)
DOH-1555 (02/2004)