Knowlton, Angenette NEW YORK STATE DEPARTMENT OF HEALTH s Z
Vital Records Section ,
Burial - Transit Permit
Name First Middle Last Sex
Angenette Rosettie Knowlton Female
Date of Death Age If Veteran of U.S. Armed Forces,
August 18, 2014 86 War or Dates
I Place of Death Hospital, Institution or
W City, Town or Village Queensbury Street Address The Stanton Nursing & Rehab. Center
Manner of Deathm
in j Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
O Suzanne Blood, M.D. Dr.
Address
14 Manor Drive Queensbury, NY 12804
Death Certificate Filed District Number R-_ister Number
City, Town or Village 'Si Q :,► vi'
El Burial Date Cemetery or Crematory
August 20, 2014 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
• and/or Address
f:: Hold
a Date Point of
❑Transportation Shipment
by Common Destination
Er 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
Cr• Address
W
a', Permission is hereby granted to dispose of the human remains described ab a as indicated.
Date Issued (a00-01� Registrar of Vital Statistics CA 0,6_P"..
}) (signature)
District NumberS(9 l Place \ 0. `,..� ofC. -e-�nSb�
I certify that the remains of the decedent identified above were disposed of inkccornce with this permit on:
W Date of Disposition 08/20/2014 Place of Disposition Quaker Road Queensbury,NY 12804
';' (address)
W
CO
re (section) (lot number (grave number)
0• Name of Sexton or Person in Charge of Premises At.,4-n picr 3 q`
Z
/� (please print)
W' Signature v`� Title CMtoRiot,
(over)
DOH-1555 (02/2004)