Nevens, Isabelle NEW YORK STATE DEPARTMENT OF HEALTH # 1'60
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Isabelle Mary Nevens Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 11, 2013 85 War or Dates
F=
Place of Death Hospital, Institution or
W City, Town or Village Fort Edward Street Address FORT HUDSON HEALTH CARE FAC.
Manner of Death Natural Cause n Accident Ei Homicide El Suicide EiUndetermined El Pending
0 Circumstances Investigation
W Medical Certifier Name Title
CI Charlene Harrington PA
Address
327 BroaDWAY Fort Edward, NY 12828
Death Certificate Filed District Num er Register Number
,,. City, Town or Village �s"�3-3 ig
❑Burial Date Cemetery or Crematory
March 12, 2013 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z El Removal and/or Held
0 and/or Address
Hold
11
Date Point of
t . I I Transportation Shipment
(1") by Common Destination
a Carrier
Disinterment Date Cemetery Address
ElReinterment 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
F}_-' Remains are Shipped, If Other than Above
Address
tX
W,
13. Permission is ere granted to dispose of the human ains describ abov as indicated.
Date Issu / e Registrar of Vital Statisti
( ignature
District Numbe Place � ---i- 2,ltel
•
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Lu Date of Dis osition3�4�t , r �I?--/
L(,i p � Place of Disposition Y t rJ�Z \(
2 (address)
CO
Et (section) ���iJv�j�mber) (grave number)
0' Name of Sexton P rso ' arge of Premises3 �T 4
(.lease prin L
Signature Title % 1 //$7'
(over)
DOH-1555 (02/2004)