Duckett, Joan NEW YORK STATE DEPARTMENT OF HEALTH .,�
Vital Records Section Burial Transi Permit
Name First Middle Last Sex
Joan Marie Duckett Female
Date of Death Age If Veteran of U.S. Armed Forces,
May 4, 2012 53 War or Dates
Place of Death Hospital, Institution or
W City, Town or Village Scotia Street Address
W Manner of Death J Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
its Ageel Gillani, M.D. Dr.
Address
100 Park Street, Pryne Pavillian Glens Falls, NY 12801
Death Certifica FiIP�d District Number Register Number
City. Town ViiIla9 c((+Ck • t1 L"I �Le;71 C O 3 r
❑Burial -Date Cemetery or Crematory
May 7, 2012 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
_E_ Hold
f Date Point of
a. ❑Transportation Shipment
by Common Destination
0: Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Reinterment
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
1.- Remains are Shipped, If Other than Above
Address
W /
CL Permission is hereb granted to dispose of the human r ains described/aa ve as-vindicated.
Date Issued 5- 57 I Registrar of Vital Statistics Z ,l L-J (✓L
// (signature)
District Number Place V f (k al c i F S ct CL i 1\_/ lti Vork
F-' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition S (ti I R_ Place of Disposition Pi 4O .) C ru.a__
2 (address)
W
ce (section) (lot number) (grave number)
a Name of Sexton or P rson in Ch rge of Premises S
/ (please print)
W"` Signature ' Yt'� Title C A'ZU'R-
(over)
DOH-1555 (02/2004)