Dutcher, Joan NEW YORK STATE DEPARTMENT OF HEALTH ft J C,
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Joan Lena Dutcher Female
Date of Death Age If Veteran of U.S. Armed Forces,
September 21, 2014 83 War or Dates
I' Place of Death Hospital, Institution or
w City, Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death Natural Cause ❑ Accident 0 Homicide ❑ Suicide 1-1 Undetermined ❑ Pending
U Circumstances Investigation
W Medical Certifier Name Title
C' F. Bollinger, MD
Address
QuPPnshin-y, Ny
Death Certificate Filed District Number 5UN
Regist�e Number
City, Town or Village _ 4 9 1
❑Burial Date Cemetery or Crematory
Sep 23, 2014 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
• and/or Address
H Hold
6 Date Point of
a. ❑Transportation Shipment
CO by Common Destination
CI Carrier
Date Cemetery Address
El 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
2 Address
a:
W
a. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued Q l 2 3/ ; t' Registrar of Vital Statistics e c k 4—vQ. W.'
(signature)
District Number 5. 60/ Place 6 (. S V-cx t\s ;N y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition ()unify Place of Disposition Quaker Road Queensbury,NY 12804
s (address)
W
12 (section) /� (lot number) (grave number)
®▪ Name of Sexton or Person in Charge of Premises ^t++ , nrigi
Z (please print)
W Signature G`fi — 'i,-,-- Title CR,1 ie-
(over)
DOH-1555 (02/2004)