Whitney, Antoinette NEW YORK STATE DEPARTMENT OF HEALTH t `. # CD Z3
Vital Records Section Burial - Transit Permit
' Name First Middle Last Sex
Antoinette Josephine Whitney Female
Date of Death Age If Veteran of U.S. Armed Forces,
October 1, 2014 90 War or Dates
Place of Death Hospital, Institution or
wi City, Town or Village Granville Street Address INDIAN RIVER REHAB & HLTH CARE
Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide n Undetermined ri Pending
Circumstances Investigation
W Medical Certifier Name Title
W
Nawed Siddiqui, M.D. Dr.
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Registe Number
City, Town or Village 57
❑Burial Date Cemetery or Crematory
October 6, 2014 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z Removal and/or Held
o and/or Address
p Hold
O Date Point of
o
a. ❑ Transportation Shipment
by Common Destination
3 Carrier
ElDisinterment Date Cemetery Address
ElReinterment 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
)--' Remains are Shipped, If Other than Above
2' Address
CE
W`
11., Permission is hereby granted to dispose of the human remains descr'• - ,, . • .4 indicated.
Date Issued 1019 I IN Registrar of Vital Statistics 4 ••:. 0
(signature)
District Number 5-0-9 Place 11t I for c4 ciCAIU die--
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 10/06/2014 Place of Disposition Quaker Road Queensbury,NY 12804
W (2 grave lot, (address)
EX ol?sspsner one ,J(lot numbe .- (grave number)
p• Name of Sexton or Person in Charge of Premises r,s ._ )is Aft
z (pl ase print)
W Signature it 4r Title CiwMktV✓Z
(over)
DOH-1555 (02/2004)