Cook, Trinity NEW YORK STATE DEPARTMENT OF HEALTH 107
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Trinity Star Cook Female
Date of Death Age If Veteran of U.S.Armed Forces,
February 14, 2015 .1.4‘, War or Dates
Place of Death Hospital, Institution or
W City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
14 Medical Certifier Name Title
Jennifer Bashand, Dr.
Address
Women's Care, 45 Hudson Ave. Glens Falls, NY 12801
Death Certificate Filed District NumbgL`eI Register Nylnber
mi, City, Town or Village
k 3❑Burial Date Cemetery or Crematory
February 17, 2015 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or
Address
E Hold
!?:'° Date Point of
,` ❑Transportation Shipment
i_-B by Common Destination
Carrier _
❑ Disinterment
Date Cemetery Address
-c
El Reinterment
Date Cemetery Address
,, Permit Issued to Registration Number
Ag 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
-s Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
IZ
lit
,, Permission is hereby granted to dispose of the human remains described above as indicated.
f Date Issued 21/ '2 I 1 Registrar of Vital Statistics (,! lA),.---crg
gli (sign Lure)
E
District Number 5 Co1 Place 6 Le,5 ro, `,'\<, aJ
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
7---,_ Date of Disposition 02/17/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number) (grave number)
Name of Sexton or Perso in C rge of Premises -
AA :_cul ,
V (please plfnt)
Signature Title
e"IN-4-wi 1-�"l"
(over)
DOH-1555 (02/2004)