Lemery, Marion NEW YORK STATE DEPARTMENT OF HEALTH "$l7
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
`� Marion Rae Lemery Female
Date of Death Age If Veteran of U.S. Armed Forces,
February 24, 2018 82 War or Dates
wPlace of Death Hospital, Institution or
City, Town or Village Hudson Falls Street Address 11 McDowell Street
CI Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide 0 Undetermined ❑ Pending
Ili
0 Circumstances Investigation
U Medical Certifier Name Title
Mary Stine, NP
Address
West Mountain Health Care Facility Queensbury, NY 12804
Death Certificate Filed District Number Register Number
City, Town or Village 5726 J-
"; , 0 Burial Date Cemetery or Crematory
February 26, 2018 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑
Removal and/or Held
and/or Address
Hold
07 Date Point of
A. ❑Transportation Shipment
by Common Destination
13 Carrier
❑ Disinterment Date Cemetery Address
Date Cemetery Address
❑ 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
8i Name of Funeral Firm Making Disposition or to Whom
1-v- Remains are Shipped, If Other than Above
2 Address
C
W
IL Permission is hereby granted to dispose of the human remains scribed above as indicated.
> Date Issued -0Z.e.—/ ' Registrar of Vital Statistics
(signature)
District Number 5726 Place '),. Qere �c+ o o ,�
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W,
Date of Disposition 02/26/2018 Place of Disposition Quaker Road Queensbury,NY 12804
;' (address)
Ui
IX (section) ,g/(lot number.- (grave number)
0; Name of Sexton or Person in Charge of Pre ises (4,74v,ti, isv tt
(please print)
LL1 Signature Title ttEr4 'L
(over)
DOH-1555 (02/2004)