Couglar, Stella NEW YORK STATE DEPARTMENT OF HEALTH I it 70
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Stella Dumont Couglar Female
Date of Death Age If Veteran of U.S. Armed Forces,
_ December 9, 2014 91 War or Dates
f Place of Death Hospital, Institution or
iii City, Town or Village Hudson Falls Street Address 31 LaFayette Street
W Manner of Death IT
Natural Cause 0 Accident El Homicide 0 Suicide ElUndetermined El Pending
Circumstances Investigation
a_ Medical Certifier Name Title
4 John Sawyer, MD,
Address
453 Dixon Rd Queensbury, NY 12804
Death Certificate Filed District Number Register Number
City, Town or Village S- 7) G ) -1-
❑Burial Date Cemetery or Crematory
j Z \ \\ \ V-\ Pine View Crematorium
❑Entombment Address
. EiCremation Quaker Road Queensbury,NY 12804
Date Place Removed
Removal and/or Held
and/or Address
i,.. Hold Union Cemetery
10-= Date Point of
Transportation Shipment
VI by Common Destination
Carrier
Disinterment Date Cemetery Address
-- 0 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
F- Remains are Shipped, If Other than Above
2 Address
W'
14"` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued// - // -;G /y Registrar of Vital Statistics ari t.k& , 6
(signature)
District Number 7 d 6 Place (/, /tap_ G -4 60 fra l/S
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
h,.
W' Date of Disposition - 4/ /Place of Disposition Quaker Road Queensbury,NY 12804
(address)
Ur 19 Dumont
14
14 (section) ,....5-7e20.441t umber / (grave number)
0, Name of Sexton o n Char of Premises
, ,. (please Situr Title 0 /7/7
� 1,
(over)
DOH-1555 (02/2004)