Chick, Barbara NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - i ransit Permit
1 Name First Middle Last Sex
Barbara Elizabeth Chick Female
Date of Death Age If Veteran of U.S. Armed Forces,
October 13, 2015 86 _ War or Dates
I— Placeof Death Hospital, Institution or
W City, Town or Village Queensbury Street Address The Stanton Nursing & Rehab. Center
0 Manner of Death rzn
Natural Cause ❑ Accident El Homicide El Suicide ❑ Undetermined ❑ Pending
W Circumstances Investigation
0;
W 1 Medical Certifier Name Title
01 Kenneth France,
Address
I 170 Warren Street Glens Falls, NY 12801
Death - . . ate Filed �,I,, District tuber Register Number
Cit , own or illage j (A
Cit r. K`l I(OS
❑B - Date Cemetery or Crematory
October 14, 2015 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z f Removal and/or Held
O l— and/or Address
H Hold
t) Date Point of
0O, I I Transportation Shipment
(I) by Common Destination
O Carrier
Date Cemetery Address
C Disinterment
Date Cemetery Address
❑ 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
I- Remains are Shipped, If Other than Above
M Address
W
a' Permission is hereby granted to dispose of the human remaips�dc�s r� p ibe ab a cat; .
Date Issued 10—I44 _ Registrar of Vital Statistics b�(,��C %. '
(signature)
District Number Sl9 Place 40(.4.7Y1 ate.
I,.
I certify that the remains of the decedent identified abov ere disposed of in - cordanc- ith this permit on:
W Date of Disposition 10/14/2015 Place of Disposition uaker Road Quee - ► ;04
M (address)
W
U)
X (section) P1 (lot number (grave number)
pName of Sexton or Person in Charge of Premises ` 'f'� )^"•'t
zdi A— Y(please print)
Signature Title aton4frit
(over)
DOH-1555 (02/2004)