Nix,Baby NEW YORK STATE DEPARTMENT OF HEALTH I Z I
Vital Records Section `- Burial - Transit Permit
Name First Middle Last Sex
Baby Nix Female
Date of Death Age If Veteran of U.S. Armed Forces,
01/27/2021 1 0 years War or Dates
p— Place of Death Hospital, Institution or
City, Tgi!ngtr ( Glens Falls Street Address Glens Falls Hospiiit I
W Manner of Death❑Natural Cause ❑Accident ❑Homicide 0 Suicide ❑Undetermined El Pending
Circumstances Investigation
W Medical Certifier Name Title
G Danielle Goertzen MD
Address
90 South Street Glens Falls, NY 12801 '
DeathCertificate Filed District Number Register Number
City, Tqg m Vitm Glens Falls 5601 2
❑Burial • Date Cemetery or Crematory
❑Entombment 02/01/2021 Pine View Cematory
Address
DCremation Queensbury, Ny •
Date Place Removed
Z Removal and/or Held
✓ L-I and/or Address
ta Hold
bp Date Point of
to Li Transportation Shipment
C 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. 00281
Address
68 Main Street Hudson Falls, N Y 12801
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
,'; Address
i
lit
"` Permission is hereby granted to dispose of the human remai described above as indicated.
Date Issued 02/01/2021 Registrar of Vital Statistics CS 'i
(signal!
District Number 5F01 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
/4---
Mt• Date of Disposition Z13i2i Place of Disposition
s'' (address)
tEE
>l
(section) (lot numbe (grave number)
ti Name of Sexton or Person in C arge of Premise ' IA
.44
2 (please rint)
lifSignature Title lhl^+'Kat
(over)
DOH-1555 (02/2004)
Public Health Law Sec. 4145(2b) 014487
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#