South, Sandra NEW YORK STATE DEPARTMENT OF HEALTH ` ` 5—
Vital Records Section Burial - Transit Permit
A-1 Name First Middle Last Sex
,€ Sandra Jean South Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 29, 2014 61 War or Dates
1"'1 Place of Death Hospital, Institution or
a City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death IV,
Eu Natural Cause El Accident 0 Homicide El Suicide 0Undetermined El Pending
Circumstances Investigation
LLM Medical Certifier Name Title
0 Edit Masaba,
Address
35 Gilbert Street Cambridge, NY 12816
' Death Certificate Filed District Number ' Register Number
' City, Town or Village ...5J
❑Burial Date Cemetery or Crematory
January 2, 2015 Pine View Crematorium
l Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
Removal
� and/or Held
and/or Address
pi Hold
Date Point of
Transportation Shipment
by Common Destination
Carrier
0 Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
a Name of Funeral Home Carleton Funeral Home, Inc. 00281
;.i Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
74-1 Name of Funeral Firm Making Disposition or to Whom
lei Remains are Shipped, If Other than Above
M Address
Ili
IL,
Permission is hereby granted to dispose of the human remains described above as indicated.
Date issued ) I 2- I IL--
_Registrar of Vital Statistics L3c,LA R U\.)pi-
,, (signatur
District Number c o l Place 6(siv \\, id y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 01/02/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
Llt;
t!►
le (section) 4 (lot number) (grave number)
Name of Sexton or Person i Char of Premises ( t't (--
(please print
'' Signature • Title atrinivt
(over)
DOH-1555 (02/2004)