Courture, Olive NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Olive Mae Couture Femal e
Date of Death Age If Veteran of U.S. Armed Forces,
August 11, 1996 94 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Qu��Y Street Address West Mount Health Facility
Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Richard S. Spitzer MD
Address
NX
Glens Falls Hospital, Glens Falls, NY 12801
Death Certificate Filed QUeensbury District Number Register Number
CV towno e 5657
Date Cemetery or CremaXor
El Burial August 12, 1996 Pine VieV Crematorium
Address
ffCremation Tn of Queensbury, NY 12804
Date Place Removed
Z ❑Removal and/or Held
•- and/or Address
Hold
Q Date Point of
❑Transportation Shipment
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 remain described above as i icated.
js,Date Issued $-/1--! Registrar of Vital Statistics
(signature)
Queensbury, NY
District Number SZoS 7 Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f- n 1 n
w Date of Disposition Place of Disposition�. ly '\L �1 F
..2 (address)
W
N
t1E (se /n,) t m`b�r) �(grave number)
GName of Sexton or Person in Charge of Premises}�� "tom U`+ ►y 1
z (please print) _ rrvv11 '�1
Signature Title C, "' t'�V4to� Z
DOH-1555 (10/89) p. 1 of 2 VS-61