VanAernem, Carol NEW YORK STATE DEPARTMENT OF HEALTH i 1 # 75
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Carol Ann VanAernem Female
Date of Death Age If Veteran of U.S. Armed Forces,
January 25, 2014 68 War or Dates
Place of Death Hospital, Institution or
ili City, Town or Village Kingsbury Street Address 108E Queens Drive
Manner of Death 0 Natural Cause 0 Accident ❑ Homicide ❑ Suicide 0 Undetermined El I---' Pending
CircumstancesInvestigation
tW Medical Certifier Name Title
Michael Sikirica MD,
Address
50 Broad Street Waterford, NY 12188
Death - --. icate Filed District Number Register Number
City, own'.r Village V' h1,S 5 / 5 7 , 0 y
0 Burial Date Cemetery or Crematory
January 29, 2014 Pine View Crematorium
❑Entombment Address
,' ®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z 11-1 l Removal and/or Held
0, and/or Address
E Hold
fh Date Point of
❑Transportation Shipment '
CO by Common Destination
O Carrier
ElDisinterment Date Cemetery Address
sx =III Reinterment
Date Cemetery Address
Permit Issued to Registration Number
i, 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
L, Remains are Shipped, If Other than Above
• Address
Ce
W'
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued /- k-..2CIc/ Registrar of Vital Statistics S 2 _ "-a'- %
(signature)
District Number Z Place '
S! � OfiJ� o�\ �1J 6 uY�
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w; Date of Disposition 01/29/2014 Place of Disposition Quaker Road Queensbury,NY 12804
q (address)
lik
(section) lot number) Cc (grave number)
0 Name of Sexton or Person in Charge f Premises rts1 e `�'✓1+`1
Z (pi base print)
Ili Signature /4°j-- Title 0201R-711/,
(over)
DOH-1555 (02/2004)