Devivo, Peggy NEW YORK STATE�DEPARTMENT OF HEALTH ' 1 5t
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Peggy Yvonne DeVivo Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 4, 2015 82 War or Dates
Place of Death Hospital, Institution or
• City, Town or Village Granville Street Address INDIAN RIVER REHAB & HLTH CARE
0 Manner of Deathinj Natural Cause ❑ Accident 0 Homicide 0 Suicide ❑ Undetermined ri❑ Pending
Circumstances Investigation
LI
W` Medical Certifier Name Title
O Nawed Siddiqui, M.D. Dr.
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Dumber
City, Town or Village �. `�
❑Burial Date Cemetery or Crematory
March 5, 2015 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal _ and/or Held
C , and/or Address
i... Hold
' Date Point of
.0 Transportation Shipment
0 by Common Destination
0 Carrier
Date Cemetery Address
El Disinterment
❑ Reinterment 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
F Remains are Shipped, If Other than Above
Address
IX
III
Permission is herebygranted to dispose of the human remai • - - •lit v- as indicated.
Date Issued 3)5 1' Registrar of Vital Statistics W/ .tV' ie-
(signature)
_� District Number 57)6 Place \t tti of- Cciattu ((Q-
RA I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
yam..
W Date of Disposition 03/05/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
W
V)
(section) (lot umber) (grave number)
0' Name of Sexton or Person in arge of Premises �: 'tpu `S�*
(please nt)
"t Signature f2 Title fire t-
(over)
DOH-1555 (02/2004)