Grant, Renee J i 27,
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Renee' Louise Grant Female
Date of Death Age If Veteran of U.S. Armed Forces,
August 4, 2015 53 War or Dates
F— Place of Death Hospital, Institution or
C i
w ty, Town or Village Glens Falls Street Address Glens Falls Hospital
WManner of Death m Natural Cause 0 Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
;; Circumstances Investigation
W Medical Certifier Name Title
a Eric Pillemer, M.D. Dr.
Address
102 Park Street Glens Falls, NY 12801
Certificate Filed District Number Registe r
(Cj Town or Village �/L r' s llama u s- 5601
❑Burial Date Cemetery or Crematory
August 5, 2015 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
H Hold
N Date Point of
pa,, ❑Transportation Shipment
(I) by Common Destination
❑'' Carrier
❑ Disinterment Date Cemetery Address
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
2 Address
Cr
W /'
O. Permission is hereby granted to dispose of the human r�nain ribed ahlove s Indic ed.
Date Issued 6 �64,�- Registrar of Vital Statistics f&,�� �i � �
/ (signature)
District Number 5601 Place G� e--41
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 08/05/2015 Place of Disposition Quaker Road Queensbury,NY 12804
2` (address)
Wd.
CO (section) x (lot number) (grave number)
a' Name of Sexton or Person in Char a of Premises A,$.1L' 5,44''
(please print)
W
Signature � Title (1(4k Ftr-NL
(over)
DOH-1555 (02/2004)