Hall, Marijane NEW YORK STATE DEPARTMENT OF HEALTH '131
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Marijane L Hail Female
Date of Death Age If Veteran of U.S. Armed Forces,
,.- 05/28/2018 63 Years War or Dates
_' Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Ci Manner of Death ralLA j Natural Cause El Accident I=1 Homicide El Suicide ri Undetermined n Pending
Circumstances Investigation
tu Medical Certifier Name Title
, Frances Bollinger MD
Address
j 100 Park St,Glens Falls,New York 12801
7:, Death Certificate Filed District Number Register Number
a City, Town or Village Glens Falls 5601 270
0 Burial Date Cemetery or Crematory
05/30/2018 Pine View Crematorium
❑EntombmentLA rm Address
®Cremation Queensbury Town, New York
Date Place Removed
Z, Q Removal and/or Held
and/or Address
5 Hold
O Date Point of
0 ❑Transportation Shipment
7g
by Common Destination
Carrier
f.
Disinterment Date Cemetery Address
' Date Cemetery Address
b. Reinterment
'" Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
p Address
68 Main Stpo Box 67,Hudson Falls,New York 12839
Name of Funeral Firm Making Disposition or to Whom
t Remains are Shipped, If Other than Above
• Address
UJ'
Permission is hereby granted to dispose of the human remains described above as indicated.
4- Date Issued 05.'30/2018 Registrar of Vital Statistics Mat Curtis ectronicaffy Signed)
(signature)
y
▪i' District Number 5601 PlaCe Glens Falls, New York
I,;; I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Ui Date of Disposition {i f$ or Place of Disposition CL t� *-•1/4,
2 (address)
Ili
(section) (lot n tuber) (grave number)
Name of Sexton or Person in Charge f Premises } L J.,.,.�,t
z (pl se print)
ILI Signature Title at-
(over)
DOH-1555 (02/2004)