Harrington, Carolyn NEW YORK STATE DEPARTMENT OF HEALTH 751
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Carolyn Estella Harrington Female
Date of Death Age If Veteran of U.S. Armed Forces,
April 18, 2015 67 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Hudson Falls Street Address 1 St. Paul Drive Apt 5A
Manner of Death .] Natural Cause n Accident Homicide Suicide ❑ Undetermined El❑ Pending
Lfi
Circumstances Investigation
it Medical Certifier Name Title
Michael Fuller, Dr.
Address
East Street Fort Edward, NY 12828
Death Certificate Filed District Number Register Number
City, Town or Village Hudson Falls j 7 6 L.
❑Burial Date Cemetery or Crematory
April 21, 2015 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑
Removal and/or Held
and/or Address
E Hold
4
Date Point of
nTransportation Shipment
by Common Destination
0 Carrier
1-1
I Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079
Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remans scribed above as indicated.
Date Issued 7-a�I a 0/. Registrar of Vital Statistics � . t.. " `�.-^<--
(signature)
District Number S 76 a Place S ,
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 04/21/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
E' (section) f(lot number (grave number)
Name of Sexton or Person in Charge of Premises,+,
( lease pnnt)
Signature t/" /� Title (Peirmin
T
(over)
DOH-1555 (02/2004)