Carlozzi, Marianne NEW YORK STATE DEPARTMENT OF HEALTH # 513
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Marianne Carlozzi Female
Date of Death Age If Veteran of U.S.Armed Forces,
11/08/2012 75 War or Dates
Place of Death Hospital, Institution or // ,1 -4Rfvlyty--
w City, Town or Village Queensbury Street Address Deceased's Residence
Manner of Death❑ Natural Cause 0 Accident 0 Homicide Suicide El Undetermined Pending
ILI
0 Circumstances Investigation
W Medical Certifier Name Title
W
WILLIAM C. ORLUK, / f/}-
Address
6223 State Rte 9 Chestertown, NY 12817
Death Certificate Filed District Number ' Register Number
City, Town or Village Rif/S-2 N7
❑Burial Date or r ato c—.---
['Entombment 11/09/2012 7tWY.d7P L/2e tom' /0i.i y1d
Address t2 aa l Xr..7
®Cremation ?�-.mod--e-w-i�/ , (/ /).1 L%
Date Place Removed
zriRemoval and/or Held
0 and/or Address
Hold
0 Date Point of
0 Transportation Shipment
Ui by Common Destination
i Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00141
Address
9 Pine St/P.O. Box 455 Chestertown NY 12817
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped, If Other than Above
2 Address
W
a. Permission is hereby granted to dispose of the human rema- des ribed above s indicated.
Date Issued Registrar of Vital StatisticsGxL� /'1
If -Q-yule
(signature)
District Number 6b5--, Place 6,,, ,c., -D
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition ii/J3)it Place of Disposition .iU kw G s7m"-tc)rt✓r.
2 (address)
W
CO
EC (section) (lot number) (grave number)
d Name of Sexton or Person in Charge o Premises A a s SC744
(please print)
W Signature L� Title (/zzrfP-L OIL
(over)
DOH-1555(02/2004)