Lodge, Jean NEW YORK STATE DEPARTMENT OF HEALTH if ��
Vital Records Section l s Burial - Transit Permit SS
1 Name First Middle Last Sex
Jean Alice Lodge Female
Date of Death Age If Veteran of U.S. Armed Forces,
July 25, 2015 88 War or Dates
F— Place of Death Hospital, Institution or
w
W City, Town or Village Fort Edward Street Address FORT HUDSON HEALTH CARE FAC.
O Manner of Death NI Natural Cause 111 Accident 0 Homicide 0 Suicide riUndetermined ri Pending
W
U Circumstances Investigation
W Medical Certifier Name Title
0 Daniel C Larson M.D.,
Address
9 Carey Road Queensbury, NY 12804
Death Certificate Filed District Number Register Number
City, Town or Village es'7SC 79- -
❑Burial Date Cemetery or Crematory
July 28, 2015 Pine View Cemetery
❑Entombment Address
®Cremation Quaker Rd. Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
p and/or Address
Hold
0 Date Point of
a ❑Transportation Shipment
t/) by Common Destination
D Carrier
Disinterment Date Cemetery Address
EiReinterment 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
I— Remains are Shipped, If Other than Above
O2C Address
w
a" Permission is h reb ranted to dispose of the human .ins-describe ove indicated.
Date Issued �� Registrar of Vital Statist'
f (signatu )
District Numbers Place
I certify that the remains of the decedent identified a ove were disposed of in accordance with this permit on:
W Date of Disposition 07/28/2015 Place of Disposition Quaker Rd. Queensbury,NY 12804
2 `")-3.-,5 F address)
tT1«U e &toirei
W (se�tion) (lot number) (grave number)
a Name of Sexton or Person i Char a of Premises (tine_ u•el-kJ C Crean cc or•e v AN
(please print)
W Signaturelf,� Title Cre,i Lr., A-34 .
(over)
DOH-1555 (02/2004)