Fiore, Mary NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Mary Marcia Fiore Female
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Date of Death Age
If Veteran of U.S.Armed Forces,
January 11, 1992 66 War or Dates
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Place of Death Hospital, Institution or
�; City,Town or Villagplens Falls Street Address Eden Park Nursing Hose
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Manner of Death rbNatural Cause Accident ❑Homicide Suicide Undetermined Pending
11nn�� Circumstances Investigation
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Medical Certifier Name Title
p Robert L. Evans MD
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Address
11 Irongate Center, GLENS FALLS, NY 12801
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Death Certificate Filed District Number Register Number
City,Town or Village City Glens F I s 5601
Date Cemetery or Crematory
C1Burial January... 14 : 1992 Pine,v.iew,..Cre:m.atp.ry..::............
remation Address
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Z Date Place Removed
O ' Removal and/or Held
F- and/or Hold ::::.. ....... .......-: ........
Address
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a Date Point of
cn Transportation by Shipment
p Common Carrier p
Destination
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Disinterment Date Cemetery Address
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Reinterment Date Cemetery Address
El Permit Issued to Registration Number
Name of Funeral Firm Carleton Funeral Hose Inc. 00307
A Address
P.D. Box 67, 68 Main St., Hudson Falls, N.Y. 12839
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1—: Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
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Permission is hereby granted to dispose of the human mains escribed above as indicated.
Date Issued Y Registrar of Vital Statistics
(signature)
District Numbe Place
I certify that the remains of the decedent identified above were disposed of yin accordance with this permit.own:
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Z Date of Disposition ��— Place of Disposition
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U) (section) (lot number) (grave number)
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°p' Name of Sexton Person in h:::�
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DOH-1555 (10/89) p. 1 of 2 VS-61