Bacon, Joyce NEW YORK STATE DEPARTMENT OF HEALTH f
. 1 Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Joyce Edith Bacon Female
- Date of Death Age If Veteran of U.S. Armed Forces,
August 6, 2014 79 War or Dates
I-- Plac: I ath Hospital, Institution or
tu City, ' .j or Village Fort Edward Street Address FORT HUDSON HEALTH CARE FAC.
0 Manner of Death X Natural Cause 0 Accident 0 Homicide Ej Suicide Undetermined ri Pending
111 Circumstances Investigation
U.1- Medical Certifier Name Title
I Philip J Gara Jr. MD,
Address
327 Broadway Fort Edward, NY 12828
Deat ificate Filed Dist Nu ,r Regis r Number
......._...
City, ow r Village t. F cl,.004a • ,D-]n
0 Burial Date Cemetery or Crematory
August 7, 2014 Pine View Crematorium
❑Entombment Address
a ®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z Q Removal and/or Held
and/or Address
E Hold St. Mary's Cemetery
CO' Date Point of
cEl Transportation Shipment
by Common Destination
O Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
- Permit Issued to Registration Number
4„ 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
Remains are Shipped, If Other than Above
2. Address
U1
0. Permission is hereby g anted to dispose of the huma r ins described b ve s indicated.
- Date Issued Registrar of Vital Statistic 1 /
(signature)
District NumbeL5-1S5 Plac T ZL)7 . ( — JOA
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tu Date of Disposition 08/07/2014 Place of Disposition Quaker Road Queensbury,NY 12804
2:, (address)
11.1
Ix (section) / lot number) (grave number)
Name of Sexton or Person in Charge of Premises G r'�� �'
z (pleaqe
W' SignatureZ it Title ra•c#41*
(over)
DOH-1555 (02/2004)