Coleman, Louise NEW YORK STATE DEPARTMENT OF HEALTH �.
Vital Records Section ABurial - Transit vermit
Name First Middle Last Sex
Louise P. Coleman Female
Date of Death Age If Veteran of U.S. Armed Forces,
September 24, 2012 98 War or Dates
Place of Death Hospital, Institution or
li City, Town or Village Queensbury Street Address STANTON HEALTH & REHAB CTR.
G3; Manner of Death 0 Natural Cause ElAccident n Homicide ElSuicide ❑ Undetermined ❑ Pending
WJI Circumstances Investigation
LLI W' Medical Certifier Name Title
Suzanne M Blood, MD,
Address
4'` 14 Manor Dr. Queensbury, NY 12804
Death Certificate Filed Dist Number R ister Number
City, Town or Village C c )a
0 Burial Date Cemetery or Crematory
September 26, 2012 Pine View Crematorium
` ❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
0, and/or Address
F: Hold
Date Point of
❑ Transportation Shipment
0 by Common Destination
CI Carrier
Date Cemetery Address
❑ Disinterment
I I 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
Il Remains are Shipped, If Other than Above
2 Address
ft
1.11
1.1' Permission is hereb granted to dispose of the human r ins described abov a ' dicated.
dDate Issue 1 4400 Registrar of Vital Statistics CI,
�--, (signature)
District Number�j(�c� Place ) 0 t�rl C_?h Q L,,-
. I certify that the remains of the decedent identified above were disposed of in accorda ce with his permit on:
Lu Date of Disposition 1ILll1Z Place of Disposition .atikJ C.r fotit.,-
2 (address)
WiX'
(section) / (lot number) /- (grave number)
0 Name of Sexton or Person in Charge f Premises GG/�h/ °� cep
(please print)
Signature a Title CO 1jTb�,
(over)
DOH-1555 (02/2004)