Bain, Judith NEW YORK STATE DEPARTMENT OF HEALTF`
17.
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Judith Bain Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 24, 2013 77 War or Dates
li P of Death Hospital, Institution or
uj ity Town or Village Glens Falls Street Address Glens Falls Hospital
anner of Death Q Natural Cause ❑ Accident Homicide ❑ Suicide Undetermined Pending
111
0 Circumstances Investigation
W'' Medical Certifier Name Title
0 Dean Reali, MD,
Address
Glens Falls Hospital Glens Falls, NY 12801
th Certificate Filed /�, ' r�� � ' / District Number,�/ Register,peer
City Town or Village V` 7/ ��j /o(
urial Date Cemetery or Crematory
March 28, 2013 Pine View Crematorium
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z D Removal and/or Held
• and/or Address
H Hold
N Date Point of
Transportation Shipment
N by Common Destination
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
I_ Remains are Shipped, If Other.than Above
2 Address
ce
d Permission is hereby granted to dispose of the human remains described above as jndicated.
Date Issued 3 j2.,_ ,-( ( Registrar of Vital Statistics CA) .iv k-•,--•<0.
(signature)
District Number 5 6 0 ( Place ��S \c , iv
▪ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W, Date of Disposition 3-29-13 Place of Disposition RN0WO arrebf iv-
2 (address)
W
CO
it (section) (lot number) (grave number)
Q Name of Sexton or Per on in Charge of Premises di (lot
t.
� ( ease print)
W Signature G Title COED
(over)
DOH-1555 (02/2004)