Cahoon, Evelyn Naomi-Rae NEW YORK STATE DEPARTMENT OF HEALTH • V IT -2
Vital Records Section Burial - Transit Permit
7 Name First Middle Last Sex
Evelyn Naomi-Rae Cahoon , Female
Date of Death A e 7 If Veteran of U.S. Armed Forces,
July 10, 2021 War or Dates
Place of Death Hospital, Institution or
W' City, Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death .i Natural Cause El Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
0 Circumstances Investigation
W Medical Certifier Name Title
al Kathryn Leopold, M.D. Dr.
Address
45 Hudson Ave. Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village 50O t
❑Burial Date Cemetery or Crematory
July 12, 2021 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
O and/or Address
Hold
CO Date Point of
a. ❑Transportation Shipment
(0 by Common Destination
El Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
El Reinterment
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
M' Address
W
Permission is hereb granted to dispose of the human rema"s described as indicated.
Date Issued 7113/Zc.! Registrar of Vital Statistics
(sig ture)
District Number )c ) Place Glens �(.2I)5/ NV
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 07/12/202.1 Place of Disposition Quaker Road Queensbury,NY 12804
W (address)
N
W (section) 4'lotnumber)( (grave number)
DName of Sexton or Perso) Charge of Premises 1I �itpL web..
a (plea e print)W Signature 7,) _ Title � �
(over)
DOH-1555 (02/2004)
Public Health Law Sec. 4145(2b) 014939
Receipt
Human remains of f _ ; delivered on f , 20T
A
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#