Hernandez, Margo NEW YORK STATE DEPARTMENT OF HEALTH 55D
Vital Records Section i It
Burial - Transit Permit
Name First Middle Last Sex
Margo P Hernandez Female
Date of Death Age If Veteran of U.S. Armed Forces,
July 24, 2015 87 War or Dates
f— Place of Death Hospital, Institution or
2= City, Town or Village Queensbury Street Address The Stanton Nursin• & Rehab. Center
CI
Manner of Death Natural Cause ❑ Accident ❑Homicide ❑ Suicide ❑ Undetermined ❑ Pending
W Circumstances Investigation
W Medical Certifier Name Title
In Suzanne M Blood, MD,
Address
14 Manor Dr. Queensbury, NY 12804
Death Certificate Filed District Number Register` Number
City, Town or Village 5l, '7
5
❑Burial Date Cemetery or Crematory
July 27, 2015 Pine View Crematorium
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
F Hold
Date Point of
a. ❑Transportation Shipment
tl) by Common Destination
Lei' Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Reinterment
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
M Address
CK
WCL'
Permission is hereby granted to dispose of the human remains ,d�escribed above as indicated.
Date Issued I ID.1 ldol� Registrar of Vital Statistics ` - \ej
(signature)
District Number 1 Place Ol)(-cAC by l
y
I certify that the remains of the decedent identified above ere disposed of in accordance with this permit on:
I—
I- virnc v;e W Cr-e 4o r"i
w Date of Disposition 07/27/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
W
CO
te (section) j ,,(lot number) (grave number)
aName of Sexton or P rson in Ch ge of Premises irh0 , I AQue
Z (please pant)
W Signature yam- Title Cf-en or) )45-
(over)
DOH-1555 (02/2004)