Rivers, Rebecca NEW YORK STATE DEPARTMENT OF HEALTH if . -- i
s
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Rebecca Dene Rivers Female
Date of Death Age If Veteran of U.S. Armed Forces,
May 31, 2013 47 War or Dates
f'" Place of Death Hospital, Institution or
WCity, Town or Village Fort Edward Street Address 6 Parry Street
Manner of Death I I Natural Cause n Accident 0 Homicide 0 Suicide 0 Undetermined 0 Pending
Circumstances Investigation
W Medical Certifier Name Title
0 Max Crossman, M.D. Dr.
Address
Whitehall Family Health Whitehall, NY 12887
Death Certificate Filed District Number Register Number
City, Town or Village S9SS' -3-2—'"
0 Burial Date Cemetery or Crematory
June 6, 2013 Pine View Crematorium
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z [1 Removal and/or Held
O I I and/or Address
p Hold
_
40 Date Point of
0 Transportation Shipment
CO by Common Destination
C) Carrier
iiiDisinterment 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
2 Address
W
W ,
a' Permission is hereby granted to dispose of the human remains escribed e as indicated.
Date Issued !v/4 43 Registrar of Vital Statis . s
(signature)
District Number 5,-)SS-- Place �� IU 4GZell
• I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w; Date of Disposition to(1 II Place of Disposition 7...10u..✓ (rotl-
2 (address)
Wco
:'
ce (section) (l number) r
(grave number)
0
zName of Sexton or Per n in Charge of remises a',)r J " t[a.. _)t'K'V►
(please .nnt)
W Signature Title ' lie
(over)
DOH-1555 (02/2004)