Stern, Carol ifi
NEW YORK STATE DEPARTMENT OF HEALTH "►t r S S 1Vital Records Section i Burial - Transit Permit
Name First Middle Last Sex
Carol Ann Stern female_
Dateof Death Age If Veteran of U.S. Armed Forces,
Sept 1 9, 201 3 71 War or Dates -O-
f- Place of Death Hospital, Institution or
W g4Yx� or Village Hudson_ Falls Street Address 5 William St _
CI Manner of Death INatural Cause Accident n Homicide Suicide n Undetermined n Pending
W, Circumstances Investigation
UI Medical Certifier Name Title
Austin Tsao MD
Address
Greenwich, NY
Death Certificate Filed District Number Register Number
City i,p&Village Hudson Falls 57 a Co It
0 Burial Date Cemetery or Crematory
Sep 20, 2013 Pine View Crematorium
0 Entombment Address
DOcemation Queensbury, NY
Date Place Removed
z r Removal and/or Held
0,I— and/or Address
pi Hold
0 Date Point of
c„. C Transportation Shipment
CO by Common Destination
3 Carrier
r-i
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address 68 Main St
Hudson Falls, NY
Name of Funeral Firm Making Disposition or to Whom
I-, Remains are Shipped, If Other than Above
,2 Address
al.,''
n..' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued ?-a o-aa c3 Registrar of Vital Statistics �\"'X""` a CJ C "-e-�
(signature)
District Number 5-7c,(0 Place village of Hudson Falls, NY
I certify that the remains of the decedent identified above were disposed of in accordance with�� this permit on:
W, Date of Disposition 1114113 Place of Disposition -(�+uvitij Cwrcitfs...
M (address)
W;
C (section) (lot number) c' (grave number)
0 Name of Sexton or Perso in Charge of remises AiltrMi Jt'i' 11-
ase print)
W' Signature G!71— Title «/
(over)
DOH-1555 (02/2004)