Aurelia, Irene NEW YORK STATE DEPARTMENT OF HEALTI-1 t Jv
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Irene Ann Aurelia Female
Date of Death Age If Veteran of U.S. Armed Forces,
November 30, 2013 92 War or Dates
Place of Death Hospital, Institution or
iii City, Town or Village Fort Edward Street Address FORT HUDSON HEALTH CARE FAC.
la Manner of Death 0 Natural Cause � Accident Homicide Suicide Undetermined Pending
WF, Circumstances Investigation
ti
W Medical Certifier Name Title
r Daniel C Larson M.D.,
Address
9 Carey Road Queensbury, NY 12804
Death Certificate Filed District Number Register Number
City, Town or Village J2fS 71
❑Burial Date Cemetery or Crematory
December 3, 2013 Pine View Cemetery
❑Entombment Address
®Cremation Quaker Rd. Queensbury,NY 12804
Date Place Removed
t El Removal and/or Held
0
and/or Address
F-F Hold
Date Point of
CI
ti. 0 Transportation Shipment
41 by Common Destination
,—
CI Carrier
Disinterment Date Cemetery Address
6 ' 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
F; Remains are Shipped, If Other than Above
Address
Cr
ut
d Permission is hereby granted to dispose of the human remai esFribed . •o as indicated.
Date Issued ,/,„2-,3J,43 Registrar of Vital Statisti O ��,/
(signature)
District Number "'-Place .
(.9c
I certify that the remains of the decedent identified above were disposed of ifaccordance with this permit on:
F
W' Date of Disposition 12-S-(3 Place of Disposition "w -
(address)
111
Ceo
(section) (lot number) (grave number)
i It Name of Sexton or Person . Charge of remises f' i/A.11
(pl ase print)
It Signature J Title /411437)t'
(over)
DOH-1555 (02/2004)