Bakay, Eleanor NEW YORK STATE DEPARTMENT OF HEALTH , - 'ii a Ci3
Vital Records Section Burial - Transit Permit
Name First Middle • Last Sex
Eleanor May Bakay Female
Date of Death Age If Veteran of U.S. Armed Forces,
July 13, 2015 78 War or Dates
Ei Place of Death Hospital, Institution or
Lu City, Town or Village Queensbury Street Address 275 Aviation Road
iLu
W' Manner of Death Natural Cause ❑ Accident 0 Homicide El Suicide 0 Undetermined ❑ Pending
W Circumstances Investigation
kU Medical Certifier Name Title
:1 John Sawyer, MD,
Address
453 Dixon Rd Queensbury, NY 12804
Death • • ate Filed District Number Register Number
City own or illage Rusevisbur 5L 1 -` -
❑Buna Date Cemetery or Crematory
July 14, 2015 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
F Hold Pine View Crematorium
CO Date Point of
. ❑
f Transportation Shipment
07 by Common Destination
❑; 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
H Remains are Shipped, If Other than Above
2 Address
w
a. Permission is hereby granted to dispose of the human re ain saibed a ve icate .
Date Issued I-1 4- Registrar of Vital Statistics
Lim (signature)
' District Number S671 Place otu),\. tilkt.ie n
,
I certify that the remains of the decedent identified abov were disposed of in ac •r•ance with this permit on:
w; Date of Disposition 07/14/2015 Place of Disposition f'uaker Road Quee -b ,NY 12804
`'i V (address)
Cf?.
I (section) (lot number) (grave number)
in Name Name of Sexton or Person in Charge of PremisesI
, +� �- 3tn
Z-
11 (please print)
Di Signature ' Title (44104,
(over)
DOH-1555 (02/2004)