McKenzie, Mary Cornelia ti /b 0
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Mary Cornelia McKenzie Female
Date of Death Age If Veteran of U.S.Armed Forces,
01/23/2021 102 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Moreau Town Street Address 198 Bluebird Road,Moreau Town,New York 12803
`p Manner of Death NI Natural Cause Accident Homicide El SuicideUndetermined Pending
U Circumstances Investigation
W Medical Certifier Name Title
CI Madison Zuis NP
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Moreau 4562 7
▪Burial Date Cemetery,Crematory or Facility Name
01/26/2021 Pine View Crematorium
❑Entombment Address
O Cremation Queensbury Town,New York
▪Donation
Removal Date Place Removed
and/or and/or Held
- Hold Address
0
d 1-1 Date Point of
t/)❑Transportation
CI by Common Shipment
Carrier Destination
El
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address
68 Main Street,P.O.Box 67,Hudson Falls,New York 12839
Name of Funeral Firm Making Disposition or to Whom
1- Remains are Shipped,If Other than Above
Address
W
a. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/25/2021 Registrar of Vital Statistics Leeann 9Kc cube(EEectronica1ty Signed)
(signature)
District Number 4562 Place Moreau, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W▪ Date of Disposition I/z7)zj Place of Disposition IL eior,,,._
2 (address)
W
CC (section) (lot number) (grave number)
• Name of Sexton or Person in Charge of Pre ises �ry -S.f^"^1��T
Z (p*ase print)
W Signature / Title test"1+TVrt
(ram
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 0--4'
Receipt
66
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on butial permit
Official Funeral Directors Reg.or License#