Floyd, Lois NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Eq Lois Iva Floyd Female
Date of Death Age If Veteran of U.S. Armed Forces,
May 11, 2015 82 War or Dates
(4; Place of Death Hospital, Institution or
W City, Town or Village Fort Edward Street Address FORT HUDSON HEALTH CARE FAC.
C3: Manner of Death rriu Natural Cause ❑ Accident ❑Homicide ❑ Suicide ❑ Undetermined ri❑ Pending
,W Circumstances Investigation
W Medical Certifier Name Title
o Philip Gara, M.D. Dr.
A Address
Broadway Fort Edward, NY 12828
Death Certificate Filed Dist Nu Regittnumber
City, Town or Village
` A❑Burial Date Cemetery or Crematory
May 13, 2015 Pine View Crematorium
❑Entombment
Address
`'®Cremation Quaker Road Qum • NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
1 Hold KINGSBURY CEMETERY
Date Point of
Transportation Shipment
( by Common Destination
Carrier
❑ Disinterment
Date Cemetery Address
E Date Cemetery Address
❑ Reinterment
,..,',I, Permit Issued to Registration Number
Fr Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
k Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
_° Name of Funeral Firm Making Disposition or to Whom
ice' Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human ins escr be b as indicated.
44, Date Issued 6-13 SDI 5 Registrar of Vital Statistics ,
(signature)
District Number57 5 Place �}yl � tuuu
.. .„,,,
7 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ut Date of Disposition 05/13/2015 Place of Disposition Quaker Road Queensbury,NY 12804
2 (address)
I
1 . (section) ,(lot number) (grave number)
3 Name of Sexton or Person in Charge of Premises 1Z1, . S -
/ (pl ase print)
Signature �`` Title t�4 To
' (over)
DOH-1555 (02/2004)