Cornell, Betty NEW YORK STATE DEPARTMENT OF HEAI.TH t 7,1 g
Vital Records Section / _ Burial - Transit Permit
Name First Middle Last Sex
Betty Louise Cornell Female
Date of Death Age If Veteran of U.S. Armed Forces,
May 31, 2012 96 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address
w Manner of Death 0 Natural Cause ill Accident E Homicide El Suicide ❑ Undetermined El 1--I Pending
CircumstancesInvestigation
W: Medical Certifier Name Title
Ct Trevor A. Litchnase, M.D
Address
2 Broad Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village lP<---) 7 5�
0 Burial Date Cemetery or Crematory
June 4, 2012 Pine View Crematorium
;,0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
O and/or Address
H Hold
(1) Date Point of
❑ Transportation Shipment
by Common Destination
Carrier
Date Cemetery Address
❑ Disinterment
❑ Reinterment 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
I- Remains are Shipped, If Other than Above
2 Address
rt
u
'IL" Permission is hereby granted to dispose of the human rem ins described ab v as indicated.
Date Issued ,-aoi L. Registrar of Vital Statistics
1. (signature)
District Number 66 5--, Place ( `.�( _A_- 3 7/
1� I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
II•
w Date of Disposition ;/Slit Place of Disposition Pim i.1 Creitr fits--
2 (address)
11.1
CO
ft (section) !liti
(lot number) �, (grave number)
▪ Name of Sexton or Person in C arge of Premises ��`p�`� �"""�
I'p/ease print)
W Signature ILTitle Cne 6Pt16'2
(over)
DOH-1555 (02/2004)