Edwards, Geraldine NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - iran it Permit
Name First Middle Last Sex
Geraldine Alice Edwards Female
Date of Death j Age If Veteran of U.S. Armed Forces,
July 18, 2012 93 War or Dates
H Place of Death Hospital, Institution or
Z W City, Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death 171 Natural Cause ❑ Accident ❑ Homicide D Suicide ❑ Undetermined ri❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
CI Marvin Davidowitz, M.D
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village 5 60 ( 3 t
❑Burial Date Cemetery or Crematory
July 20, 2012 Pine View Crematorium
❑Entombment Address
Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
p. Hold
CO Date Point of
tx, ❑Transportation Shipment
60 by Common Destination
Carrier
ElDisinterment Date I 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
i-- Remains are Shipped, If Other than Above
2 Address
Ce
W°
1 tL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued '7 f?c )(2 Registrar of Vital Statistics ,�v) ( � LA.)�J (s___L.,‘„tirst
ignature)
District Number 560( Place 6 U,,,"`5 \\c i 7 (2$G
H I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 1 7 t-lIZ Place of Disposition 0*+Ukv Ctti-itaf WI-,
(address)
W
CO
ft (section) (lot number) (grave number)
pName of Sexton or Per •n in Charg- of Premises AtS �t�`d�
z / (pl ase print)
la1 Signature A A Title
�2t�Ml��-TaIG
(over)
DOH-1555 (02/2004)