Brooks, Helen NEW YORK STATE DEPARTMENT OF HEALTH ; # 3
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Helen Reed Brooks Female
, Date of Death Age If Veteran of U.S. Armed Forces,
December 29, 2012 96 War or Dates
Place of Death Hospital, Institution or
f City, Town or Village Fort Edward Street Address
CI Manner of Death X❑ Natural Cause ElAccident ❑Homicide ❑ Suicide ❑ Undetermined El❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
John Layden MD,
Address
90 South St. Glens Falls, NY 12801
Death Certificate Filed District Number Regis er Number
City, Town or Village , 5`j-5-Y--"
❑Burial Date Cemetery or Crematory
January 2, 2013 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date ' Piace Removed
z ❑ Removal and/or Held
and/or Address
I! Hold
0- Date Point of
❑ Transportation Shipment
CO by Common Destination
0 Carrier
❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
g Permit Issued to Registration Number
f "K. 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
( Remains are Shipped, If Other than Above
Address
ir
tit
O. Permission is h eb granted to dispose of the hums ins describe bove s indicated.
Date Issued/� Registrar of Vital Statisti z.,
—__—__ (signature/
District Numbet )i Place .4524 n C % 1 4
I certify that the remains of the decedent identified above were disposed of in accordancec `with this permit on:
WDate of Disposition i-u-i3 Place of Disposition -1,t1f+wr C '�or+ar-
; (address)
w
Co (section) 4 (lot number) (grave number)
0 Name of Sexton or Person in Charge of P emises G hn3 �e�►�,
0: (p/ ase print)
Signature dila., Title c � 3��
(over)
DOH-1555 (02/2004)