Keech, Tammy NEW YORK STATE DEPARTMENT OF HEALTH �� tb
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Tammy Alice Keech Female
Date of Death Age If Veteran of U.S. Armed Forces,
August 11, 2013 49 War or Dates
F- Place of Death Hospital, Institution or
WCity, Town or Village Glens Falls Street Address Glens Falls Hospital
El
LiJ Manner of Death Natural Cause � Accident Homicide Suicide Undetermined Pending
i l Circumstances Investigation
kii Medical Certifier Name Title
0. William Borgos MD,
Address
14 Manor Drive Queensbury, NY 12804
Death Certificate Filed District Numb`,- Register Number
City, Town or Village
❑Burial Date Cemetery or Crema ory
August 15, 2013 Pine View Crematorium
"`❑Entombment
Address
®Cremation I Quaker Road Queensbury,NY 12804
Date Place Removed
z0 Removal and/or Held
and/or Address
E Hold
U7' Date Point of
a. 0 Transportation Shipment
O by Common Destination
0I Carrier
Disinterment 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
f_ Remains are Shipped, If Other than Above
2 Address
Ce
tL Permission is he eby granted to dispose of the human remains described above as indicated.
Date Issued " Registrar of Vital Statistics W .")`'
(signature)
District Numbeks,-. 6/ Place r- j2 / /
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 1/iCI13 Place of Disposition -{��ctJt,_ CedYretaran.--
(address)
.01
IX (section) (lot number) r` (grave number)
O Name of Sexton or Per zn
Charge Premises Atu'�v r �\J Q"nitf
(please print)
Ul Signature Title intvro1k
(over)
DOH-1555 (02/2004)