Pinkowski, Mary h33L
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First , ;:' . Last Sex
Mary Pauline -a Pinkowski Female
Date of Death Age If Veteran of U.S. Armed Forces,
May 21, 2014 85 War or Dates
Z' Place of Death Hospital, Institution or
W City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death 0 Natural Cause ❑ Accident ❑Homicide ❑ Suicide ❑ Undetermined ❑ Pending
LU
Circumstances Investigation
W Medical Certifier Name Title
0 Shahid Ahmed, M.D
Address
Death Certificate Filed District Number Register Number
City, Town or Village 5601 a1..i'
❑Burial Date Cemetery or Crematory
May 23, 2014 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road, Queensbury
Date Place Removed
z ❑ Removal and/or Held
and/or Address
_ Hold
CO
Date Point of
0. ❑Transportation Shipment
_ by Common Destination
CI Carrier
Date Cemetery Address
❑ Disinterment
ElDate 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
L. Remains are Shipped, If Other than Above
Address
IX
11. Permission is hereby granted to dispose of the human remains described above aq indicat d.
Date Issued j/2 3 //t" Registrar of Vital Statistics ��,��,� �-\Q,. � .
(signature)
District Number 5601 Place 6 "V"S 1 \s r G" y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 05/23/2014 Place of Disposition —g.ta ) Crr rsw
(address)
U Burial in Sar
00
NOBiO (lot number) � (grave number)
CI a Name of Sexton or Perso. in Charge of Premises i
(please print)
14 Signature Title CKil k.
(over)
DOH-1555 (02/2004)