Michon, Claire NEW YORK STATE DEPARTMENT OF HEALTH 4 1 1%
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Claire Susan Michon Female
Date of Death Age If Veteran of U.S. Armed Forces,
April 3, 2012 59 War or Dates
I Place of Death Hospital, Institution or
Lu City, Town or Village Glens Falls Street Address 161 Bay St.
WManner of Death❑ Natural Cause 0 Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
W Circumstances Investigation
W Medical Certifier Name Title
C Michael Sikirica MD,
Address
50 Broad Street Waterford, NY 12188
Death Certificate Filed Distri mb 1 Register Number
City, Town or Village 49-1
0 Burial Date Cemetery or Crematory
April 6, 2012 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
• and/or Address
F Hold
N Date Point of
j0 ❑Transportation Shipment
Cl) by Common Destination
❑; Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
El Reinterment
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
1— Remains are Shipped, If Other than Above
• Address
IX
LLl
CL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 0 4 1 5 J )z_ Registrar of Vital Statistics W .A, ,Q k.A.)
(signa ure)
District Number S 6 O I Place 6 S PA us , N
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition ? ,1 ( 1°42 Place of Disposition /1„�L.) Crenatt�„
1 (address)
W
re (section) (lot number) (grave number)
D' Name of Sexton or Person in Charge o Premises �nsfir- S#0/cf-
Z (please print)
LU Signature ./" Title CQC(Mkt-Cq2.
(over)
DOH-1555 (02/2004)