Proctor, Kristie 3S
NEW YORK STATE DEPARTMENT OF HEALTH it "l
Vital Records Section Burial - Transit Permit
iiiiiiii Name First Middle Last Sex
Kristie Ann Proctor Female
Date of Death _Age'' If Veteran of U.S. Armed Forces,
08/21/2012 27 years War or Dates 2002-2012
Place of Death Hospital, Institution or
CAM( -own or➢O W Clifton Park Street Address 203 Walnut Dr., Clifton Park, NY
1/4
0 Manner of Death❑Natural Cause El Accident 0 Homicide El•Suicide El Undetermined El Pending
Circumstances Investigation
0.
at Medical Certifier Name Title
John De Martino Coroner
Address
339 Northline Road, Ballston Spa, Ny 12020
: Death Certificate Filed District Number Register Number
® own or VCIMAX Clifton Park 4552 86
'0 Burial Date Cemetery or Crematory
08/23/2012 Pine View Crematory
,:: ❑Entombment Address
[}Cremation Queensbury, N Y
Date Place Removed •
gri Removal and/or Held
and/or
1;; Address
CC
Hold
0 Date • • Point of
❑irk
Transportation Shipment
a by Common Destination
Carrier
on Disinterment Date Cemetery Address
giiEl Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home 00281
_ > Address
PO Box 67, 68 Main St. Hudson Falls, NY 12839
ikENEI Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
i
itt
11„:: Permission is hereby granted to dispose of the human - s described bo as in is d.
08/22/2012r
Date Issued Registrar of Vital Statistic i
(signature)
District Number Place
4552 Clifton Parr
;;: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LUU Date of Disposition (r�3-IZ. Place of Disposition PP4 i Ciw- or(u,
1 (address)
IX (section) A . (lot number)r, (grave number)
O.
Name of Sexton or Person in Char e of Premises i F(isk44,- JtNH,
I (please print)
Signature1)4L Title Crlitzln A nt,
(over)
DOH-1555 (02/2004)