Addison, Elizabeth NEW YORK STATE DEPARTMENT OF HEALTH rilli"--
Vital Records Section Burial - Transit ermit
Name First Middle Last Sex
Elizabeth Addison Female
Date of Death Age If Veteran of U.S. Armed Forces,
January 28, 2013 85 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address 75 Sherman Ave
W Manner of Death j Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
W Circumstances Investigation
UJ Medical Certifier Name Title
William A Tedesco MD,
Address
17 Pine St. Hudson Falls, NY 12839
Death Certificate Filed District Nurpbs ,o / Register N.�mber
City, Town or Village �� /�L
❑Burial Date Cemetery or Crematory
January 29, 2013 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
E Hold
*I Date Point of
11 ❑Transportation Shipment
0; by Common Destination
CI Carrier
Date Cemetery Address
❑ Disinterment
ElRenterment 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
2 Address
CC
a' Permission is he eby ranted to dispose of the human rains d cribed a ove as ind'
Date Issued -0/ Registrar of Vital Statistics / 'i� lJ yam., /,�`-C
`Il l (s nature)
District Number J' / Place 44 .i---/L...-,A.-e. ,
I certify that the remains of the decedent identified above were disposed of in accordanc with this permit on:
Z Date of Disposition p I-31'l'3 Place of Disposition et,t14,0,4 CroN1c{ps,✓N,.
W (address)
CO
ir 0 (section) l/ (lot number) (grave number)
a Name of Sexton or Person in Charge of Pr:mises 4
z
please print)
W Signature G-- Title C =r�
irn
(over)
DOH-1555 (02/2004)