Granger, Marjorie NEW YORK STATE DEPARTMENT OF HEALTH e '_ A 24,
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Marjorie Shirley Granger Female
Date of Death Age If Veteran of U.S.Armed Forces,
January 9, 2015 95 War or Dates
IPlace of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address FORT HUDSON HEALTH CARE FAC.
CY LitManner of DeathEL] Natural Cause 0 Accident El Homicide ID Suicide 0Undetermined ri Pending
Circumstances Investigation
W Medical Certifier Name Title
Charlene B. Harrington,
Address
T. _ 327 Broadway Fort Edward, NY 12828
Deat ificate Filed District Nu Register Number
. City, ow or Village �fw�"J55
c0
❑Burial Date _Tot vi (L Z 0 (S Cemetery or Crematory
/ Pine View Crematorium
`, 0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z riRemoval and/or Held
and/or Address
F- Hold
CO Date Point of
Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Date CemeteryAddress
Reinterment
Ac 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
Remains are Shipped, If Other than Above
. Address
'ii
: Permission is hereb granted to dispose of the human re ' s descri ed ab ve as -ndicated.
Date Issued t /i 2) 15 Registrar of Vital Statistics
si nature
District Number') IA.5 5 Place O a t cm a
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W' Date of Disposition 1/1Its Place of Disposition o1 Quaker Road Queensbury,NY 12804
(address)
CO Burial on
. T )Lot in (lotnumber) (grave number)
0
Ca Name of Sexton or Person in Charge of Premises ii►itiiL ie
z (p ase print)
L/L 2 C✓M1 I-
�; Signature �, Title (1
(over)
DOH-1555 (02/2004)