Hart, Mary NEW YORK STATE DEPARTMENT OF HEALTH 1 3Sv
Vital Records Section `� , ' Burial - Trans! Permit
�'Name First Middle Last Sex
Mary Anne Hart Female
Date of Death Age If Veteran of U.S. Armed Forces,
July 10, 2012 65 War or Dates
P Place of Death Hospital, Institution or
_ ity;)Town or Village Glens Falls Street Address Glens Falls Hospital
_nner of Death Lu Natural Cause Accident El Homicide 0 Suicide Undetermined Pending
Ul
C Circumstances Investigation
W Medical Certifier Name Title
C] Aqeel A. Gillani, M.D. Dr.
Address
102 Park St Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
1 own or Village �7es /X J--fff ,
I Burial Date Cemetery or Crematory
July 12, 2012 Pine Vew Crematorium
❑Entombment Address
®Cremation Queensbury,NY 12804
Date Place Removed
zri Removal and/or Held
and/or Address
F. Hold
CO Date Point of
act, 0 Transportation Shipment
by Common Destination
CI 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
Name of Funeral Firm Making Disposition or to Whom
--R, Remains are Shipped, If Other than Above
2 Address
W
Permission is hereby granted to dispose of the human remains descri dd above in
Date Issued /20/4 Registrar of Vital StatisticsI�;�„! -
(signature)
District Number /' Place 6/e/7 la/,S/ ' "/ /o'Or
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W 2
Date of Disposition 7-1 -t2 Place of Disposition 12►0Ail1J u Cr,.r er tof
2 (address)
W
CO
iX (section) (lot number) r_ (grave number)
a Name of Sexton or Pers in Charge QQf Premises A
'St 5i,,ff
(please print)
W Signature Title C►1 e"'i1 L°k
(over)
DOH-1555 (02/2004)