Malmberg, Lydia NEW YORK STATE DEPARTMENT OF HEALTH 1111
Vital Records Section , , i Burial - Transit Permit
Name First Middle Last Sex
Lydia Annalise Malmberg Female
Date of Death Age //,Th If Veteran of U.S. Armed Forces,
August 17, 2013 V War or Dates
I— Place of Death Hospital, Institution or
W City, Town or Village Glens Falls Street Address Glens Falls Hospital
CI Manner of Death a Natural Cause n Accident El Homicide n Suicide FlUndetermined ri❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
t
Address '
`I5 '
1I, as3 ,, 1;u. . , C i� 5 R.-1-- . / ;)..L1
Qath e Certificate Filed District Number / Register N mber
C Cit own or Village Co(c..+m S )- a k( t
0 Burial Date Cemetery or Crematory
August 20, 2013 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z Removal and/or Held
0 and/or Address
F Hold Pine View Cemetery
Date Point of
Q.. n Transportation Shipment
(0 by Common Destination
d` 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
I— Remains are Shipped, If Other than Above
2' Address iL
W'
t3.' Permission is hereby granted to dispose of the human remains described above as in 'cated.
Date Issued g/2-0//3 Registrar of Vital Statistics W - ,e
(signature)
District Number ,j 6 0 f Place 6 cQhS ` s / 0 1/41
--, I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W' Date of Disposition $ll7_J s Place of Disposition gLIA La Cro tfo s,
2, (address)
W
C (section) / jlot number) C (grave number)
0 Name of Sexton or Person . Charge of emises �` ) eo
M g (ple se print)
WTitlebhp
Signature � T04.-
(over)
DOH-1555 (02/2004)