Gardner, Debra NEW YORK STATE DEPARTMENT OF HEALTH 41 611 2,
Vital Records Section • *IA Burial - Transit Permit
Name First Middle Last Sex
Debra Joy Gardner Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 4, 2012 , 43 War or Dates
Place of Death Hospital, Institution or
Ili City, Town or Village Hudson Falls Street Address 293 Main Street
13 Manner of Death rznNatural Cause Accident Homicide Suicide Undetermined Pending
III
0 Circumstances Investigation
W Medical Certifier Name Title
0 Max Grossman, M.D. Dr.
Address
North St. Granville, NY 12832
Death Certificate Filed District Number Register Number
City, Town or Village
❑Burial Date Cemetery or Crematory
December 7, 2012 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z El Removal and/or Held
a and/or Address
.; Hold
0 Date Point of
❑Transportation Shipment
by Common Destination
3< 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
f-, Remains are Shipped, If Other than Above
Address
ck:
ill
fig Permission is hereby granted to dispose of the human remain described above as indicated.
Date Issued 12-6-2012 Registrar of Vital Statistics -----"—"'-_____.
(signature)
District Number 5726 Place Village of HUdson Falls, NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Lu Date of Disposition 2-1-11 Place of Disposition 'f , �t4a Cre �r`v^-
Ci,1, p I p
2 (address)
WCe.
(section) (lo(number) (grave number)
Name of Sexton or Person in Charge of Premises pri3 �M4��-
z (p/ ase print)
W Signature AIL Title CO:AA - ,
(over)
DOH-1555 (02/2004)