Havens, Helen -11-77c
NEW YORK STATE DEPARTMENT OF HEALTH ' "1 `
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Helen Patrecia Havens Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 19, 2013 78 War or Dates
Place of Death Hospital, Institution or
w City, Town or Village Street Address
W' Manner of Death❑ Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
0 Frances Bollinger MD,
Address
161 Carey Rd Queensbury, NY 12804
F€` Death Certificate Filed District Number Register Number
City, Town or Village
❑Burial Date Cemetery or Crematory
December 19, 2013 Pine View Crematorium
Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
ElRemoval and/or Held
'0% and/or
j Hold Address
CO Date Point of
t ❑Transportation Shipment
V by Common Destination
0 Carrier
Date Cemetery Address
El Disinterment
-' Date Cemetery Address
�=,❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
j 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
- Address
CC
Uf
Permission is hereby granted to dispose of the human remain described above as indicated.
Date Issued /01- /9--/,3 Registrar of Vital Statistics remain?
9 f�
(signature)
District Number /04,..2. Place /#u'rj tJ ��'Z61tee-u
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 0-/0-I3 Place of Disposition *,LUi,J ei ecfL-
2 (address)
(section) (lot nu beP (grave number)
• Name of Sexton or Person in Char a of PremisesZ 4 '4
(please print!
Ltl. r - Title CQ, w� 1WI.
Signature
(over)
DOH-1555 (02/2004)