Center, Eva NEW YORK STATE DEPARTMENT OF HEALTH, IT WI
Vital Records Section a-t. Burial - Transit Permit
Name First Middle Last Sex
Eva Loretta Center Female
Date of Death Age If Veteran of U.S. Armed Forces,
i,:. November 10, 2014- 66 War or Dates
wPlace of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address 43 Ridge St.,Apt 312
Manner of Death Ij Natural Cause ❑ Accident ❑Homicide ❑ Suicide ❑ Undetermined ❑ Pending
uj 0 Circumstances Investigation
Cl Medical Certifier Name Title
Timothy Murphy,
Address
_'' 52 Haviland Ave Glens Falls, NY 12801
Death Certificate Filed District Number Register Number 5
City, Town or Village 5601
❑Burial Date Cemetery or Crematory
Pine View Crematorium
Au❑Entombment r Address
<,;®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
Hold
0 Date Point of
a ❑Transportation Shipment
by Common Destination
0 Carrier
ElDisinterment Date Cemetery Address
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
t.z* 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
-r Remains are Shipped, If Other than Above
Address
L. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1 i / i 2( t y Registrar of Vital Statistics LlJ
(signature)
District Number 5601 Place G C9w•-5 1 S i y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H
W' Date of Disposition II/igIiq Place of Disposition Quaker Road Queensbury,NY 12804
(address)
W Cremains to
CO ,sgsb gmas (lot number) (grave number)
t�:
C(`
Name of Sexton or Person in Charge of Premises Ar3.100 E-- Jtk
(please print)
W /J�Signature ` `''1'71- /,��— Title Cilletillercre
(over)
DOH-1555 (02/2004)