Keech, Rita NEW YORK STATE DEPARTMENT OF HEALTH
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Vital Records Section . • Burial - Transit Permit
': Name First Middle Last Sex
E;' Rita Marie Keech Female
Date of Death Age If Veteran of U.S. Armed Forces,
09/15/2018 75 Years War or Dates
H Place of Death Hospital, Institution or
city, Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
iiiCC Manner of Death J Natural Cause L Accident 0 Homicide El Suicide 0Undetermined ri Pending
In Circumstances Investigation
Medical Certifier Name Title
O Eileen Spinelli NP
Address
319 Broadway.Fort Edward Town,New York 12828
Death Certificate Filed District Number Register Number
City, Town or Village Fort Edward 5755 52
" OBurial Date Cemetery or Crematory
09/17/2018 Pine View Crematorium
❑Entombment Address
;,. ®Cremation Queensbury Town, New York
Date Place Removed
0 ❑Removal and/or Held
tir and/or Address
Hold
O Date Point of
Transportation Shipment
0 by Common Destination
a.° Carrier
❑Disinterment Date Cemetery Address
' Reinterment Date Cemetery Address
;'; Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address
i; 68 Main Stpo Box 67,Hudson Falls,New York 12839
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
ft
LIJ
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/17/2018 Registrar of Vital Statistics Aimee (Erec-trvnicallySigned)
(signature)
' District Number 5755 Place Fort Edward. New York
t„, I certify that the remains of the decedent identified above were disposed of inn accordance�► with this permit on:
ELI Date of Disposition q!I 1 l(g Place of Disposition em�� CAviv„�
(address)
Cl)ilk
IX (section) (lot n ber) ( (grave number)
0
Name of Sexton or Person in Charge of Premises t rr.4c it l A 410
(please print)
UJ Signature �� 4- ' Title (whim
(over)
DOH-1555 (02/2004)
1