White, Kathryn NEW YORK STATE DEPARTMENT OF HEALTH BurialTransit �rmit
Vital Records Section s • • , -_ Name First Middle Last Sex
Kathryn H. Yates White Female
' Date of Death Age If Veteran of U.S. Armed Forces,
September 26, 2013 gib War or Dates
i" Place of Death Hospital, Institution or
City, Town or Village Moreau Street Address Home of the Good Shepherd
ill
Manner of Death 0 Natural Cause n Accident I I Homicide ri Suicide Undetermined Pending
3 (----J Circumstances Investigation 1.14 Medical Certifier Name Title
Chris Messitt, M.D Dr.
Address
135 North Road Wilton, NY 12831
Death Certificate Filed District Number Register Number
City, Town or Village
❑Burial Date Cemetery or Crematory
September 27, 2013 Pine View Crematorium
❑Entombment Address
, v Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
CRemoval and/or Held
t_ and/or Address
F Hold
0 Date Point of
ETransportation Shipment
by Common Destination
5 Carrier
CDisinterment 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
Remains are Shipped, If Other than Above
Address
zi
* Permission is hereby granted to dispose of the human remain escribed above a indicated.
Date Issued g7,a9'/, Registrar of Vital Statistics , P��
signature)
District Number 466. a Place
71
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1-'
Place of Disposition Date of Disposition W, p iff�'(j �,,,,,��� 0,_
2.
` (address)
ie,: (section) of number) (..' (grave number)
da Name of Sexton or Person i Charge o Premises f o (.3
Z; (please print)
444 Signature Title
(over)
DOH-1555 (02/2004)
I