Rafferty, Carol NEW YORK STATE DEPARTMENT OF HEALTH 36d
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Carol Marie Rafferty Female
Date of Death Age If Veteran of U.S. Armed Forces,
06/04/2012 69 years War or Dates
H lace of Death Hospital, Institution or
>L Cit\ Tow w lil xx --Glens Fall Street Address
c Manner of Death F
Natural Cause 0 Accident 0 Homicide 0 Suicide Undetermined Pending
LLI Circumstances Investigation
la Medical Certifier Name Title
44 Anthony Petracea M D
Address
3 Irongate Plaza Glens Falls, N Y 12801
Certificate Filed District Number Register Number
C owynyiII RXX nIpns Falls 5601 273
['Burial Date Cemetery or Crematory
❑Entombment 06/07/2012 Pine View Crematory
Address
FACryemation Queensbury, NY
Date Place Removed
Z❑Removal and/or Held
9 and/or Address
Hold
U
0 Date Point of
0)*0 Transportation Shipment
C by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox& Regan Funeral Home 01821
«; Address
11 Algonkin Street Ticonderoga, N Y I a ici3
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
s
LEU
CL
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/07/2012 Registrar of Vital Statistics ("D
(signatur )
District Number 5601 Place � //Glens Falls � 1
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2 , /�
l Date of Disposition (.Wiz Place of Disposition 'i ire.Vim) C,r�wdtt0(rvoN,
2 (address)
LU
W.
CC (section) (lot number
JJ ) (grave number)
fl Name of Sexton or Person in Charge of remises (1iti -- Same
(please se print)
1ttSign Signature /// --, Title CU nhll}LO(- (over)
DOH-1555 (02/2004)