Thaxton, Deborah NEW YORK STATE DEPARTMENT OF HEALTH . `4 7
Vital Records Section Burial - Transit Permit
` I Name First Middle Last Sex
Deborah Ann Thaxton Female
Date of Death Age If Veteran of U.S. Armed Forces,
April 27, 2014 60 War or Dates
Place of Death Hospital, Institution or
ai City, Town or Village Queensbury Street Address 22 Pine Street
CI Manner of Death IliJ Natural Cause 0 Accident ❑Homicide ❑ Suicide ❑Undetermined ri❑ Pending
Circumstances Investigation
W Medical Certifier. Name Title
a Elizabeth Hutchins, ANP-C,
Address
2 Broad Street Queensbury, NY 12804
, Death Certificate Filed District Number Register Number
City, Town or Village st,.0e n s6 u-
❑Burial Date Cemetery or Crematory
May 30, 2014 Pine Vew Crematorium
;-❑Entombment
Address
,18]Cremation Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
Hold
CO Date Point of
0. ❑Transportation Shipment
G by Common Destination
'. Carrier
Date Cemetery Address
❑ Disinterment
IDReinterment 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
I Remains are Shipped, If Other than Above
Address
LL.
W
fit" Permission is hereby granted to dispose of the human remains described above as indicated.
b
Date issued a
- `t- c i Registrar of Vital Statistics �Z- J�KA,e ,
(signature)
District Number S(O 5 1 Place D'JQL(\S tVr
I certify that the remains
f the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 05/3A/2014
W p Place of Disposition Queensbury,NY 12804 fi=
X (address)
W
W (section) (lot number) (grave number)
-' Name of Sexton or Per in Charge f Premises ►vl 3 Ah, #
Z (please print)
Al Signature L'f . Title
(over)
DOH-1555 (02/2004)