Coso, Mary NEW YORK STATE DEPARTMENT OF HEALTH _ Ri tit �1. --)Yl
Vital Records Section Burial - Transit Permit
_ Name First f Middle Last Sex
Mary Palma Coso Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 1, 2014 83 War or Dates
tPlace of Death Hospital, Institution or
W, City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death 0 Natural Cause Accident Homicide El Suicide riUndetermined ri Pending
ar
Circumstances Investigation
Mk Medical Certifier Name Title
Cr Robert Love, M.D. Dr.
Address
3 Irongate Center Glens Falls, NY 12801
e h Certificate Filed �(s 01 District Number
Register er
Cit Town or Village G1{�a
❑Burial Date Cemetery or Crematory
December 2, 2014 Pine View Crematorium
, 0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Place Removed
Removal Date and/or Held
and/or Address
E Hold
aDate Point of
t ,, ❑Transportation Shipment
by Common Destination
Ct Carrier
Disinterment Date Cemetery Address
it
Reinterment
Date Cemetery Address
e Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
4`°°� Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
m Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
IAddress
Permission is hereby granted to dispose of the human remains desc �bo e � ated.
Date Issued /2 4?2/xil'/ Registrar of Vital Statistics ���
/� (signature)
District Number 5601 Place /�i� /_/4 AV
OF
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z.
Date of Disposition 12/02/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
W:
WI
(section) (lot number) (grave number)
/� _
rf rf Name of Sexton or Person in Charge of Premises
M (hr. ��
(p/ se print)
CizmiVe
Signature Title
(over)
DOH-1555 (02/2004)