Greene, Carol # 50
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Carol
Date of Death . Age If Veteran of U.S.Armed Forces,
.... July 1 2, 201 5 74 YrsWar orDates no
Z Place of Death Hospital, Institution or
Ili City Town illag Fort Ann Street Address 5 Q....George ..S.tr...,...:.A .,..:.. .. ... . ..
Ca Manner DeatT ':. at N Undetermined Pending
Cause Accident Homicide Suicide
1111
Cir
cumstances Investigation
W
Medical Certrfier Name Title
G Max Crossman
MD.
Address
Whitehall, NY. 12887
Death Certificate iled District Number Register Number
City,Town o illage Fort Ann 5723 3
P ate Cemetery or Crematory
El Burial July 13, 2015 PineView Crematorium
®Cremation Address
Town of Queensbury, NY. 12804
z Date Place Removed
O ❑ Removal and/or Held
I- and/or Hold
Address
M
........
a Date Point of
rn ['Transportation by Shipment
p Common Carrier
Destination
❑ Disinterment
Date Cemetery Address
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm
Mason Funeral Home 01117
Address
18 George St. , Fort Ann, NY. 12827
I-- Name of Funeral Firm Making Disposition or to Whom
g Remains are Shipped, If Other than Above
CC Address
I
0-
Permission is hereby granted to dispose of the human remains described above 'ndicated.
Date Issued July 1 3, 201 Registrar of Vital Statistics 'G- a.AA
(signet )
+ � '1 '
�� District Numbers 7 Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H'
Z: Date of Disposition 71 01itc Place of Disposition 'KL,../ Orkirotor
"me.`
W (address)
LLI
CO (section) p (Jot number (grave number)
CC
O Name of Sexton or Person in Charge f Premises C lreLr
Z (please print)
�� E
u ` Signature Title
VS-61
DOH-1555 (10/89) p. 1 of 2