Hamelin, Yvonne NEW YORK STATE DEPARTMENT OF HEALTH% l gii
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Yvonne Viola Hamelin female
Date of Death Age If Veteran of U.S. Armed Forces,
Nov 1 1 , 2015 90 War or Dates -o-o
I- Place of Death Hospital, Institution or
NI,
W Town or xx Kingsbury Street Address 123 North Street
W Manner of DeathLti Natural Cause Accident n Homicide Suicide 7 Undetermined Pending
U Circumstances Investigation
W Medical Certifier Name Title
O David Foote, MD
Address
Hudson Falls, NY
Death Certificate Filed District Number Register Number
Gift, Town or rffikAxxxx Kingsbury 5 7 6 a i(o
❑ Burial Date Cemetery,or Crematory
Nov. 13, 2015 Pine View Crematorium
ErEntombment Address
0 Cremation
Date Place Removed
z Removal and/or Held
and/or Address
F- Hold
0 Date Point of
eLEl Transportation Shipment
0) by Common Destination
3 Carrier
Disinterment Date Cemetery Address
ElReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc.
Addr[ess
P.o. Box 67, 68 Main St. , Hudson Falls, NY
Name of Funeral Firm Making Disposition or to Whom
I- Remains are Shipped, If Other than Above
g Address
X
W
C' Permission is hereby granted to dispose of the human remai described above as indicated.
Date Issued cZ1kU- l3 OAS Registrar of Vital Statistics .,�..o, C,30 ta-s;-<'-A....,
(signature)
District Number57&, ;Z Place Town of Kingsbury, NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W, Date of Disposition ti/i(,'ZS Place of Disposition ,Pn1 V,.. `w►..lor;u
2 (address)
W
(/)
IX (section) //��, (lot number) (grave number)
a` Name of Sexton or Person in Charg of Premises afu .Scoot
( lease print)
W Signature le Title l
(over)
DOH-1555 (02/2004)