Walrath, Marilyn NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Marilyn Louise Walrath Female
Date of Death Age If Veteran of U.S. Armed Forces,
July 24, 2012 74 War or Dates
1' j Place of Death Hospital, Institution or
W`. City, Town or Village Glens Falls Street Address Glens Falls Hospital
W' Manner of Death Natural CauseEl Accident 0 Homicide n Suicide Undetermined Pending
Circumstances Investigation
WWI Medical Certifier Name Title
_ Scott Biasetti, M.D. Dr.
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Nu ^• ` Re mber
City, Town or Village CC) t
0 Burial Date Cemetery or Crematory
July 25, 2012 Pine View Crematorium
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z 1-1 Removal and/or Held
and/or Address
F. Hold
0 Date Point of
Transportation Shipment
f!) by Common Destination
8 Carrier
ElDisinterment 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
t Remains are Shipped, If Other than Above
• Address
Cr
W
IL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 7 /25/r Z Registrar of Vital Statistics ii ' ,, )
District Number 5 6 0 f Place 6 Lk.A. s r(n\\ s, N 9- (2 y0
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition )boil Place of Disposition f L Vr yr
2 (address)
W
(00
Ce (section) A/ _ (lot number) (grave number)
O Name of Sexton or Person in Charge Premises 6//^/rw�
� (please print)
Signature Gv Title C
ONMpetoit
(over)
DOH-1555 (02/2004)