Butterfield, Thelma NEW YORK STATE DEPARTMENT OF HEALTH '1j'�
Vital Records Section Burial - Transit Permit
. , Name First Middle Last Sex
'107-
a
Thelma Butterfield \ Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 15, 2014 104 War or Dates
WPlace of Death Hospital, Institution or
: City, Town or Village Fort Edward Street Address FORT HUDSON HEALTH CARE FAC.
Manner of Death 0 Natural Cause ❑ Accident ❑Homicide ❑ Suicide ❑ Undetermined ❑ Pending
la
Circumstances Investigation
AL Medical Certifier Name Title
Bernardo R Villajuan MD,
Address
161 Carey Road Queensbury, NY 12804
Death Certificate Filed District ttier Regis er umber
City, Town or Village
❑Burial Date Cemetery or Crematory
March 18, 2014 Pine View Crematorium
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
IN Date Place Removed
.z ❑ Removal and/or Held
0 and/or Address
Hold
Date Point of
a. Transportation Shipment
by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
❑ 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
115-:4'
Remains are Shipped, If Other than Above
Address
ce
iL
Permission is ereby granted to dispose of the human re ains descri edbove s indicated.
Date Issued Registrar of Vital Statistics
(sigture)District Number r r Place6 (I certify that the remains of the decedent identified above were disposed of in accordance with this permiit on: /�— `_/ ry, vj1Date of Disposition =f_a""4 Place of Disposition Quaker Road Queensbu NY 12804 �/ iematigY
(address)
Et ? (section) C �/ /� (lot n tuber) (grave number)
Name of Sexton P so. harge of Premises %"�`/f /�i�
Z' / (please print)
4, Signature Title C Ar
i� m 7-
(over)
DOH-1555 (02/2004)