White, Alfaretta NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
-, Alfaretta Frances White Female
Date of Death Age If Veteran of U.S.Armed Forces,
March 26, 2014 94 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address The Pines
Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide 0 Suicide ❑ Undetermined ❑ Pending
SJ Circumstances Investigation
U Medical Certifier Name Title
_ Daniel C Larson M.D.,
Address
9 Carey Road Queensbury, NY 12804
Death Certificate Filed District Number Register Number
City, Town or Village S (J d t t c a
❑Burial Date Cemetery or Crematory
March 28, 2014 Pine View Crematorium
-.:r❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
.'❑ Removal and/or Held
and/or Address
`Eg Hold Pine View Crematorium
la Date Point of
IL❑Transportation Shipment
flY by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
., ❑ 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
-,St Name of Funeral Firm Making Disposition or to Whom
Fr Remains are Shipped, If Other than Above
_ Address
Lii
EL, Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 3 t 2i 111-{ Registrar of Vital Statistics L/OCA, _ V . ,ti
(signature)
District Number j G o ( Place 6 Csv,i-S \\S r N y
TM I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 03/28/2014 Place of Disposition Quaker Road Queensbury,NY 12804 { tli
'' (address)
W CFH to scatter
CD
et d* t?oihj (I umb r) (grave number)
Of Feeder LA'' d
Name of Sexton or ers n in a of Premises /
ease print) s
Signature Title 024497/1„,hic
4,.. /,L
(over)
DOH-1555 (02/2004)