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Winchell, Majel NEW YORK STATE DEPARTMENT OF HEALTH 3 Vital Records Section 4t lil Burial - Tran it Permit Name First Middle Last Sex Majel Marie Winchell Female Date of Death Age If Veteran of U.S. Armed Forces, July 18, 2012 87 War or Dates ZPlace of Death Hospital, Institution or W City, Town or Village Queensbury Street Address WESTMOUNT HEALTH CARE FACILITY 111 Manner of Death❑ Natural Cause E Accident Homicide Suicide 0 Undetermined Pending Circumstances Investigation W, Medical Certifier Name Title U Vincent D Koh MD, Address 102 Park St Glens Falls, NY 12801 De . sate Filed Di rict Nyknber gsLster Number Ci y, Town or illage a)12A ,s_ ) 0 B • Date Cemetery or Crematory July 20, 2012 Pine View Crematorium 0 Entombment Address ®Crem ation Quaker Road Queensbury,NY 12804 Date Place Removed z ❑ Removal and/or Held p and/or Address _. Hold CO Date Point of i0 El Transportation Shipment (t) by Common Destination iD 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 H` Remains are Shipped, If Other than Above 2 Address IX W— Ck". Permission is hereby granted to dispose of the human re ains described abAv, a as indicated. Date Issued Registrar of Vital Statistics- ii 12 (signature) District Numbeaoc Place ) n L � (3- ,,L L ,_- I certify that the remains of the decedent identified above were disposed of llin accordanc with his permit on: W Date of Disposition '7't4-R Place of Disposition 'CiKUk' 6144,-b(1ur., 2, (address) w C (section) A (lot number) (grave number) © Name of Sexton or Person in Charge of Premises "Sk S4Kt- ALi3 (please print) W Signature Title CRC 1A}•!0t, (over) DOH-1555 (02/2004)