Cooper, Michelle NEW YORK STATE DEPARTMENT OF HEALTH ff 33
Vital Records Section Burial - Transit Permit
k __
Name First Middle Last Sex
Michelle Marie Cooper Female
Date of Death Age If Veteran of U.S. Armed Forces,
July 6, 2014 54 War or Dates
i"` Place of Death Hospital, Institution or
W' City, Town or Village Hudson Falls Street Address 80 1/2 John Street
, Manner of Death 0 Natural Cause ❑ Accident ❑Homicide ❑ Suicide n Undetermined ri Pending
L.) Circumstances Investigation
LU Medical Certifier Name Title
Max Crossman, M.D. Dr.
Address
Whitehall Family Health Whitehall, NY 12887
Death Certificate Filed District Number Register Number
City, Town or Village 5 7 a 4 9
❑Burial Date Cemetery or Crematory
July 8, 2014 Pine Vew Crematorium
❑Entombment Address
®Cremation Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
F. Hold
Date Point of
a. ❑Transportation Shipment
CO by Common Destination
CI, Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
El 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
0C
W
C' Permission is hereby granted to dispose of the human remains described above as indicated.
erDate Issued 7 ' DUI y Registrar of Vital Statistics a
(signature)
District Number 5 7a 6 Place lr,-//G,pc //6 F San to PS
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 07/08/2014 Place of Disposition Queensbury,NY 12804
M (address)
W`
CO
Ce (section) (lot number) (grave number)
o
a Name of Sexton or Person . Charge of Premises r�st5pit. 1.•+lNi1l
Z (p/ ase print)
W Signature AL..- I'm- Title CiKw ft 1
(over)
DOH-1555 (02/2004)