Brislin, Ruth NEW YORK STATE DEPARTMENT OF HEALTH : 1 41 7O/
Vital Records Section Burial - Transit Permit
litii, Name First Middle Last Sex
Ruth Mary Brislin female
Date of Death Age If Veteran of U.S. Armed Forces,
Dec 24, 2013 80 War or Dates _0_
Place of Death Hospital, Institution or
u!', City, TRIAil3RhYsilicitike Glens Falls Street Address Glens Falls Hospital
rta
Manner of Death j Natural Cause Ei Accident Homicide Suicide Undetermined Pending
0' Circumstances Investigation
111 Medical Certifier Name Title
Farhna Kama 1 , M)
Address
Glens Falls Hospital, Glens Falls, NY
f Death Certificate Filed District Number Register T� Number 2
City, t fege Glens Falls 5601
0 Burial Date Cemetery or Crematory
Dec. 27, 2013 Pine View Crematorium
❑Entombment Address
[Cremation Tn of Queensbury, NY
Date Place Removed
Removal and/or Held
0 and/or Address
Fr Hold
Date Point of
i x Transportation Shipment
by Common Destination
Carrier
4� Date Cemetery Address
Disinterment
EllReinterment Date CemeteryXddress
Permit Issued to Registration Number
Name of Funeral Home Carl eton Funeral Romp., Tnr 00781
Address
68 Main St. Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
Cam; Remains are Shipped, If Other than Above
• Address
re
14" Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1 ./ 2_71-03
/-(Registrar of Vital Statistics I. ' r � ..�✓�r
(signature)
District Number 5601 Place City of Glens Falls, NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
wDate of Disposition la J3rho Place of Disposition 2ctO«� a-vtc--
2 (address)
ID
re, (section) (t number) C (grave number)
P Name of Sexton or Person in Charge of Premises 74,E t S¢„oil
;z'; (pleas
W.
Signature L Aal TitleE�n1 L
(over)
DOH-1555 (02/2004)