Archambault, Jeanette NEW YORK STATE DEPARTMENT OF HEALTH I /� I
Vital Records Section �- Burial - Transit Permit
}':.' Name First Middle Last Sex
Jeanette Ann Archambault Female
Date of Death Age If Veteran of U.S.Armed Forces,
March 10, 2015 87 War or Dates
Place of Death Hospital, Institution or
in City, Town or Village Fort Edward Street Address FORT HUDSON HEALTH CARE FAC.
Cl Manner of Death Natural Cause ❑ Accident ❑Homicide ❑ Suicide ❑ Undetermined ❑ Pending
W Circumstances Investigation
W Medical Certifier Name Title
Philip Gara, M.D. Dr.
Address
Broadway Fort Edward, NY 12828
Death Certificate Filed District Num r7 5 S Regis er Number
City, Town or Village
❑Burial Date Cemetery or Crematory
March 16, 2015 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
i Date Place Removed
❑ Removal
and/or Held
and/or Address
=F-+ Hold
Date Point of
4 ❑Transportation Shipment
tt), by Common Destination
C Carrier
❑ Disinterment Date Cemetery Address
Date Cemetery Address
El 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
j- Remains are Shipped, If Other than Above
• Address
ce
UJ
IL Permission is hereb granted to dispose of the human red ins described a ove s indicated.
Date Issued Registrar of Vital Statistics dill _ .s 1tik V`
�_. — �((WCI(signature)
District Number 6 �� Place J
(�
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W, Date of Disposition 03/16/2015 Place of Disposition Quaker Road Queensbury,NY 12804
2 (address)
W Sect.3 P Lot 3
CeGlAygot1 1/2 /(lot number) (grave number)
0 Name of Sexton or Person in Char a of Premises Z^A 3�'i`r
( lease print)
W Signature hL Title 112,CAVIC
(over)
DOH-1555 (02/2004)