Buerkley, Muriel NEW YORK STATE DEPARTMENT OF HEALTH 14 1/S
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Muriel Frances Buerkley Female
Date of Death Age If Veteran of U.S. Armed Forces,
November 25, 2013 89 War or Dates
Z Place of Death Hospital, Institution or
W City, Town or Village Glens Falls Street Address Glens Falls Hospital
Ck Manner of Death 0 Natural Cause 0 Accident ❑Homicide ❑ Suicide ❑Undetermined ❑ Pending
Circumstances Investigation
111 Medical Certifier Name Title
Daniel Way, M.D Dr.
Address
North Creek Health Ctr Warrensburg, NY
Death Certificate Filed District Number � ' Register Number,,
City, Town or Village ``ii
['Burial Date Cemetery or Crematory
November 27, 2013 Pine Vew Crematorium
,',❑Entombment Address
®Cremation Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
_ Hold
+n Date Point of
dEl Transportation Shipment
(I)i by Common Destination
0 Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Reinterment
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
Ce
a. Permission is hereby granted to dispose of the human remains descri ab ve i . •. - •.
Registrar of Vital Statistics
Date Issued /�,L�`�!?L.3 g
/// (signature)
District Number 52,0/ Place /. / // , N)1
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition (1-l (3 Place of Disposition `t nul/Li �, On W P `�- P i Km �s-
2 (address)
Ill
CO
Qom' (section) (lot number (grave number)
0 Name of Sexton or Person in Charge of Premises el Sh /tt
Z; (please print)
W Signature 4 43--_ Title rig'i►tt t
(over)
DOH-1555 (02/2004)