Cook, Eileen r . . 4/ 7 q
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Eileen Elizabeth Cook Female
,-5 Date of Death Age If Veteran of U.S.Armed Forces,
December 17, 2014 56 War or Dates
7-74-1
Place of Death Hospital, Institution or
Y City, Town or Village Glens Falls Street Address 4 Davis Street Apt B
iZz Manner of Death Natural Cause ❑ Accident ❑Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
W. Medical Certifier Name Title
aTimothy Murphy,
Address
'" 52 Haviland Ave Glens Falls, NY 12801
Death Certificate Filed District Number FJ��) Register Number
City, Town or Village
A Burial Date Cemetery or Crematory
December 19, 2014 Pine View Crematorium
❑Entombment Address
! k®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal
and/or and/or Held
'}. Hold
Address
0) Date Point of
❑Transportation Shipment
Ilk by Common Destination
' Carrier
❑ Disinterment Date Cemetery Address
Date Cemetery Address
I ❑ Reinterment
' Permit Issued to Registration Number
=x Name of Funeral Home Carleton Funeral Home, Inc. 00281
E 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
2 Address
CC
Permission is hereby granted to dispose of the human remains ri d v icated.
Date Issued 2 % 2Qly Registrar of Vital Statistics � G
(signature)
District Number 560/ Place -
7 A-A fv>
7T I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
,W`e Date of Disposition 12/19/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
i (section) ///�� ki(lot number) (grave number)
iName of Sexton or Person in arge of Premises (4, ��� �/
(please print)
1,41 Signature ��-- Title Cz'h="tchl
(over)
DOH-1555 (02/2004)