Legault, Beverly NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
, Name First Middle Last Sex
Beverly Ann Legault Female
ai
IV Date of Death Age If Veteran of U.S. Armed Forces,
February 14, 2018 88 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Saratoga Springsa.
Street Address WESLEY HEALTH CARE CENTER, INC
W° Manner of Death❑Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
f.9i Circumstances Investigation
W Medical Certifier Name Title
Address
`1 Death Certificate Filed District Number Register Number
MI City, Town or Village '/5 / ' 0 7
17.®Burial Date Cemetery or Crematory
- . 0 1 to( ST. ALPHONSUS CEMETERY
. 0 Entombment Address 1
['Cremation Town of Queensbury,NY
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold ST. ALPHONSUS CEMETERY
Date Point of
F0 Transportation Shipment
(0 by Common Destination
O, Carrier
;V Date Cemetery Address
AITI: Disinterment
II Reinterment Date Cemetery Address
0
::'1,11 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
Remains are Shipped, If Other than Above
sM Address
OCR
W.
Permission is hereby granted to dispose of the human remai described above as indicated.
Date Issued - 6 -! g
Re istrar of Vital Statistics _�� �/ `� LL .-$c
(signature)
District Number 7& 7 Place / `7S,` ,is , .
41 I certify that the remains of the decedent identified above were disposed of n accordance with this permit on:
ILE Date of Disposition // JJ. 6, Place of Disposition Town of Queensbury,NY
D i(z res
qs) I
( (section) ey7mber) (grave number)
ay Name of Sexton or Pe son in Charge of Premises r `- .
(please print)
iJ Signature Title
(over)
DOH-1555 (02/2004)