Packard, Mary NEW YORK STATE DEPARTMENT OF HEALTH - _ % il 3lq
Vital Records Section Burial - Transit Permit
-� Name First Middle Last Sex
Mary Jane Packard Female
Date of Death Age If Veteran of U.S. Armed Forces,
May 17, 2014 95 War or Dates
Place of Death Hospital, Institution or
ui City, Town or Village Albany Street Address
• Manner of Death❑ Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
lij_ Circumstances Investigation
W Medical Certifier Name Title
O Edit Masaba,
Address
35 Gibea St. Cambridge, NY 12816
Death Certificate Filed District Number Register Number
City, Town or Village 5�S`' J 3
❑Burial Date Cemetery or Crematory
May 21, 2014 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
.❑ Removal and/or Held
• and/or Address
F Hold
GO Date Point of
d ❑Transportation Shipment
CO by Common Destination
Cl 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
Remains are Shipped, If Other than Above
2 Address
w
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued Sf 2_ J Zoi. Registrar of Vital Statistics pct Any-.
(signature)
District Number 51,5o Place ct/\gy
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 05/21/2014 Place of Disposition Quaker Road Queensbury,NY 12804
2 (address)
W
Ce (section) diwt
(lot numb (grave number)
0 Name of Sexton or Perso 'n Char a of Premises Q'^N��
Z ( ase print)
41 Signature r Title 0704143►�-
g 1
(over)
DOH-1555 (02/2004)