Carleton, Edith NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section ,, Burial - Transit Permit
Name First `'Middle Last Sex
Edith M. Carleton Female
Date of Death Age If Veteran of U.S. Armed Forces,
07/05/2015 78 years... , War or Dates
t- Place of Death Hospital, Institution or
ITI City, Taw Y0 Saratoga Springs Street Address Saratoga Hospital
WManner of Death 0 Natural Cause Accident 0 Homicide Suicide ❑Undetermined ❑Pending
Circumstances Investigation
W Medical Certifier Name Title
Ci Heather Madigan D. O.
Address
211 Church Street, Saratoga Springs, N Y 12866
Death Certificate Filed District Number Register Number
City, T9Q Q(QC MOW Saratoga Springs 4501 334
['Burial Date Cemetery or Crematory
['Entombment Address
Pineview Crematory
Address
[ICremation Queensbury, N Y
Date Place Removed
Z❑Removal and/or Held
H and/or Address
0 Hold
0 Date Point of
a.
❑Transportation Shipment
C by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home 00448
Address
7 Sherman Ave, Corinth, New York 12822
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
a Address
CC
w
d" Permission is hereby granted to dispose of the human remain rib aboy�as ' dicated.
Date Issued 07/07/2015 Registrar of Vital Statistics _e1•
(signature)
District Number 4501 Place Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
tu W Date of Disposition -our Place of Disposition Fktou., c rn..•
(address)
tiil
U,
11 (section) _(lot num er) (grave number)
ap Name of Sexton or Person in Char of Premises • / 4€i '
Z
(please print)
iLi
Signature4 Title fi 4tIi�.
(over)
DOH-1555 (02/2004)