Fredette, Clara NEW YORK STATE DEPARTMENT OF HEALTH # rrr
Vital Records Section r - Burial - Transit Permit
Name First Middle Last Sex
Clara Mae Fredette Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 7, 2015 76 War or Dates
177 Place of Death Hospital, Institution or
W City, Town or Village Glens Falls Street Address Glens Falls Hospital
0: Manner of Death Natural Cause El Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
W Circumstances Investigation
W Medical Certifier Name Title
W
Gamal Khalifa, M.D. Dr.
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village 5601 J
❑Burial Date Cemetery or Crematory
March 10, 2015 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Plaice Removed
❑ Removal and/or Held
• and/or Addressra
Hold
t Date Point of
cL_❑Transportation Shipment
2. by Common DestinatioA
O Carrier
❑ Disinterment Date Cemetery Address
V. El Reinterment Date Cemetery Address
4 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
Remains are Shipped, If Other than Above
2 Address
a:
W"
0.: Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 3 J i p I L5 Registrar of Vital Statistics 1�� s. W�'� Und
(signature)
District Number 5601 Place 6 LMS V,\ .c , y
• I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W` Date of Disposition 03/10/2015 Place of Disposition Quaker Road Queensbury,NY 12804
2 (address)
wrt CO
(section) /f(lot number) c (grave number)
aName of Sexton or Person in Charge of Premises t "'a as yr
(Plee print)
Signature IS Title Ce21., 0
(over)
DOH-1555 (02/2004)