Leary, Phyllis NEW YORK STATE DEPARTMENT OF HEALTH 36
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Phyllis Anne Leary Female
' Date of Death Age If Veteran of U.S.Armed Forces,
April 19, 2015 72 War or Dates
Place of Death Hospital, Institution or
,' City, Town or Village Kingsbury Street Address 6 Devine Dr
' Manner of Death X❑ Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
W.
U Circumstances Investigation
al M• edical Certifier Name Title
O William Borr
`-
.ntain Health Care Facility Queensbury, NY 12804
D• eat -J. '-: e Fii ,- , �.. 1 District Number Register Number
a City, own •r V liege 12804 Ys c. 5 7 '. S
❑Buria Date , Cemetery or Crematory
El Entombment
_ Pine Vew Crematorium
Entombment Address
®Cremation Queensbury,NY� _
Date Place Removed
• ❑ Removal and/or Held
and/or Address ___ —
E Hold St. Paul's Cemetery
CO Date Point of
as ['Transportation Shipment
N by Common Destination
O 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
. Remains are Shipped, If Other than Above
N Address
CC
W'',',
777.':: Permission is hereby granted to dispose of the human remai described above as indicated.
Date Issued ' -),)_a o / c Registrar of Vital Statistics � �, '"`.r_a_ Ce 0 7----
(signature)
District Number 3 7(o a. Place 1ocli t1 B 1 S ham,
r
i I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ti Date of Disposition iii ail or Place of Disposition Queensbury,NY 12804
.Q (address)
i ,
(section) (lot number) (grave number)
' �E,„,,,or
Cat Name of Sexton or Person in Charge of Premises . !�.
,✓�(please print)
Signature A - ,._ Title rritk
(over)
DOH-1555 (02/2004)