Whiting, Harper NEW YORK STATE DEPARTMENT OF HEALTH 4 1 4-0
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
, Harper Kenna Whiting Female
4 Date of Death Age 0 If Veteran of U.S. Armed Forces,
'- November 6, 2014 War or Dates
e of Death Hospital, Institution or
i Town or Village Glens Falls Street Address Glens Falls Hospital
W nner of DeathIL.i Natural Cause El Accident 0 Homicide D Suicide ElUndetermined ri Pending
Circumstances Investigation
Ili Medical Certifier Name Title
a ALLISON Herrick,
Address
45 Hudson Ave. Glens Falls, NY 12801
' D- th Certificate Filed - _ _ District Number Regist Number
Town or Village i t I Ct 5 1-a 1 I S 5601
■ :unal Date Cemetery or Crematory
November 10, 2014 Pine View Cemetery
❑Entombment Address
®Cremation Quaker Rd. Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
a and/or Address
:.; Hold
Date Point of
A. Transportation Shipment
CD by Common Destination
CI Carrier
Disinterment
Date Cemetery Address 11
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Y, 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
Address
W.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued I I/(0/r tj Registrar of Vital Statistics (2C.A..L4- , C.AL.A.- t<e-A
rr^^'� �� (signature)
District Number 5601 Place ' S to\\S? y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
U' Date of Disposition 11/10/2014 Place of Disposition Quaker Rd. Queensbury,NY 12804
2 (address)
W'
CO.
r+ (section) it (lot number) (grave number)
pName of Sexton or Person in Charge of Premises At* Stn ifi
Z (please print)
I" Signature Ark- Title 1-t':Art"+9►4
(over)
DOH-1555 (02/2004)