Charboneau, Marion NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle LastX.
Sex
Marion Ruth Charboneau Femal
'. Date of Death Age If Veteran of U.S. Armed Forces,
Starch 24, 1997 81War or Dates
Place of Death Kingsbury Hospital, Institution or
16 Fairviev Road
City, Town or Village Street Address
Manner of Death fZ Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Bernardo R. Yillajuan ND
Address
90 South St. , Glens Falls, NY 12801
Deat ificate Filed District Nurk��[2 Register Number
3{XIV ow age Kingsbury 05 - 97
Date Cemetery or Crematory
❑Burial starch 26, 1997 Pine View Crematorium
Address
Cremation Tn of Queensbu-ry, NY 12804
gDate Place Removed
Z Removal and/or Held
0 and/or Address
Hold
Date Point of
N Q Transportation Shipment
�j by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc. 00310
Address
P. O. Box'67, 68 Main St. , Hudson Falls, N. Y. 12839
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued March 25. 19ft9istrar of Vital Statistics % F , 7���,f _
(signatu4)
5762 Kingsbury, NY 12839
District Number Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f-
LU
Date of Disposition o2✓ ' Place of Disposition z (,J e' �z4jgeje/(im
(address)
w
N
(section) (lot nu Per, ) (grave number)
Name of Sexton or Person inin
✓
g (please print) i
Signature Title
DOH-1555 (10/89) p. 1 of 2 VS-61