Cutler, Harriet NEW YORK STATE DEPARTMENT OF HEALTH c 1 A 1,11
Vital Records Section Burial - Trans t Permit
Name First Middle Last Sex
Harriet Moss Cutler Female
Date of Death Age If Veteran of U.S. Armed Forces,
July 19, 2014 84 War or Dates
H Place of Death Hospital, Institution or
tu City, Town or Village Street Address Residence
CI Manner of Death Natural Cause X❑ Accident El Homicide ❑ Suicide ElUndetermined ❑ Pending
ill
U Circumstances Investigation
W Medical Certifier Name Title
O Max Crossman MD,
Address
Whitehall Family Health Whitehall, NY
Death Certificate Filed District Number Register Number
City, Town or Village 5- "7 G 1 0
❑Burial Date Cemetery or Crematory
July 21, 2014 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ri Removal and/or Held
and/or Address
E Hold Union Cemetery
_
07 Date Point of
IO ❑Transportation Shipment
Cl) by Common Destination
8 Carrier
Disinterment Date Cemetery Address
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
E Remains are Shipped, If Other than Above
2 Address
Ce
a. Permission is hereby granted to dispose of the human rema' s described above as indicated.
Date Issued 1( ar ,u/�r Registrar of Vital Statistics � � 6 -if
u t /^ (signature)
District Number 3 al�. Place /�ccdS l"U/t G /LS
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 07/21/2014 Place of Disposition Quaker Road Queensbury,NY 12804
2 (address)
W
CO
Ce (section)
lot number) (grave number)
0. r�y�S r "di-
Name of Sexton or Person in Charge of PremisesZ k ��"
(ple se print)
W Signature Title tivErniirok
(over)
DOH-1555 (02/2004)