Dawson, Linda NEW YORK STATE DEPARTMENT OF HEALTH A J t
Vital Records Section Burial - Transit Permit
1 Name First Middle Last Sex
1 1 Linda Ann Dawson Female
Date of Death Age If Veteran of U.S. Armed Forces,
July 7, 2012 60 War or Dates
Z, Place of Death Hospital, Institution or
W City, Town or Village South Glens Falls Street Address 1 Maplewood Parkway
C1 Manner of Death Natural Cause El Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
W
C�► Circumstances Investigation
W Medical Certifier Name Title
Dr. Darcy Gaiotti-Grubbs,
Address
100 Park Street, Pryne Pavillian, Glens Falls, NY 12801
, Death Certificate Filed District Nur 112er Register Number
City, Town or Village i L/
❑Burial Date Cemetery or Crematory
July 9, 2012 Pine View Crematorium
❑Entombment Address
❑C Crernation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
Hold Sacred Heart Cemetery
O Date Point of
� ❑Transportation Shipment
(0 by Common Destination
In 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
I— Remains are Shipped, If Other than Above
2i Address
a:
W;
a. Permission is hereby granted to dispose of the human re -ins described abov s indicated.
Date Issued ?A -1„Z _ Registrar of Vital Statistics - I//all AV
(signature)
I
District Number c J5Z Place 6/ /-IUJjO4 3/ , r SOu. j (/e'/X Faits " 3/ /0210.3
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w
W Date of Disposition ' -9i-1 Z Place of Disposition 240 acv Lr r it__
2 (address)
W'
rI (section) - (lot number) (grave number)
0Name of Sexton or Per on in Charge Premises 7 i f a jt L''`"1`l—
(please print)
W Signature Title G►1434/►4fri9 t
(over)
DOH-1555 (02/2004)