Chainao, Sandra NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Sandra Kay Chainao Female
Date of Death Age If Veteran of U.S. Armed Forces,
June 23, 2015 69 War or Dates
1, I e of Death Hospital, Institution or
City Town or Village Glens Falls Street Address Glens Falls Hospital
Oner of Death® Natural Cause 0 Accident 0 Homicide ❑ Suicide Undetermined Pending
LL Circumstances Investigation
W Medical Certifier Name Title
a Jennifer Donovan, D.O.
Address
North Creek Health Center, North Creek, NY
th Certificate Filed District Number Register Number
ity, Town or Village Glens Falls 5601 3 i2-`Z
L'J Burial Date Cemetery or Crematory
June 24, 2015 Pine View Crematorium
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
zElRemoval and/or Held
and/or Address
H Hold
N Date Point of
ci, ❑Transportation Shipment
(I) by Common Destination
Cl Carrier
Disinterment Date Cemetery Address
ElReinterment Date Cemetery Address
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
LLlal_
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 6`2 9 i 1< Registrar of Vital Statistics Ve. �Z
(signature)
District Number 5601 Place 6 S vcj. \ S r Ni 91
I certify that the remains of the decedent identified abovere disposed of in accordance with this permit on:
IF- \ toe U,e W C re ni4i4-o r:'VJ''`
W Date of Disposition 06/24/2015 Place of Disposition Quaker Road Queensbury,NY 12804
2; (address)
WCO
(section ff (lot number) (grave number)
O Name of Sexton or Person Char; - of Premises ( l'mn`tL rur et k
a of. /
I (please print)
W Signature4 Title CCew,ti. ry P t
(over)
DOH-1555 (02/2004)