Sabo, Mary imcvv ruKK STATE DEPARTMENT OF HEALTH # 76c
Vital Records Section `" Burial - Transit Permit
Name First Middle Last Sex
Mary Jane Sabo Female
Date of Death Age If Veteran of U.S. Armed Forces,
April 19, 2014 83 War or Dates
Place of Death Hospital, Institution or
Lir City, Town or Village Glens Falls Street Address Glens Falls Hospital
C Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
W ❑ ❑ n n n ❑
Circumstances Investigation
1 Medical Certifier Name Title
ci Danushan Sooriabalan, M.D
Address
161 Carey Road Queensbury1 NY 12804
Death Certificate Filed District Number Register Number
City, Town or Village 5601 o2Q't,
0 Burial Date Cemetery or Crematory
K( Zr/Iy Pine View Crematorium
''❑Entombment Address
s'®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
2' Removal and/or Held
and/or Address
Hold
4 Date Point of
eL C Transportation Shipment
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
Name of Funeral Firm Making Disposition or to Whom
k-x.' Remains are Shipped, If Other than Above
Address
f
=Wv
. Permission is he by ranted to dispose of the human •'. . - -cribed . •ove as i dicat'd.
Date Issued ___ - da Registrar of Vital Statistics / ,,// A.
(signature)
• District Number 5601 Place 6lizs d S j ' o /
• I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W, Date of Disposition 4 ins ilN Place of Disposition Quaker Road Queensbury,NY 12804
(address)
f;ft (section) d
(lot numbe (grave number)
Name of Sexton or Person ' Charge of Premises `""b`
(please print)
LE Signature
Title CORPE bfv/„...
(over)
DOH-1555 (02/2004)