Ducharme, Betty NEW YORK STATE DEPARTMENT OF HEALTH ttr('
Vital Records Section Burial - Transit rermit
Name First Middle Last Sex
Betty Elizabeth Ducharme Female
p Date of Death Age If Veteran of U.S. Armed Forces,
'- November 6, 2014 84 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Saratoga Springs Street Address Mary's Haven
Manner of Death Natural Cause 0 Accident 0 Homicide 0 Suicide 0 Undetermined 0 Pending
Ail
Circumstances Investigation
ill Medical Certifier Name Title
Eric Pillemer, M.D. Dr.
Address
102 Park Street Glens Falls, NY 12801
Death Certificate File District Number Register Nur er
City, Town or Village �_!ar 2dt 10(4) j301
0 Burial Date Cemetery or Crematory
.. November 10, 2014 Pine View Crematorium
', 0 Entombment Address
`1Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
Z EliRemoval and/or Held
and/or
Hold Address
(75 Date Point of
Transportation Shipment
( by Common Destination
CIF Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Mx Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
tag
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
w Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
irt
W,
Permission is here y granted to dispose of the human rem ns de c ed a a indicat
Date Issued Registrar of Vital Statistics
(signature)
District Number y sb' Place
SARATOGA SPRINGS
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
E.7'
ui Date of Disposition 11/10/2014 Place of Disposition Quaker Road Queensbury,NY 12804
X-' (address)
w
?:IV (section) (lot number) (grave number)
C ' Name of Sexton or Person in Charge of Premises L kr.si '4
(please print)
14! Signature Title
(over)
DOH-1555 (02/2004)