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Dumond, Mary Irene NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Mary Irene Dumond Female Date of Death Age If Veteran of U.S.Armed Forces, 09/21/2021 77 Years War or Dates F,. Place of Death Hospital,Institution or Z City,Town or Village Kingsbury Town Street Address 16 Division Street,Kingsbury Town,New York 12839 111 p Manner of Death ©Natural Cause Accident ❑Homicide 1=1 Suicide ❑Undetermined El Pending W Circumstances Investigation W Medical Certifier Name Title o Jean Hanson PA Address 325 Main Street,Hudson Falls Village,New York 12839 Death Certificate Filed District Number Register Number City,Town or Village Kingsbury Town 5762 17 ElBurial Date Cemetery,Crematory or Facility Name 09/22/2021 Pine View Crematorium ElEntombment Address X❑Cremation Queensbury Town,New York ElDonation Z ❑Removal Date Place Removed and/or and/or Held H Hold Address N Oa Date Point of Cl) ❑Transportation t Shipment p by Common Carrier Destination Date Cemetery Address ❑Disinterment 1=1Reinterment 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 F Remains are Shipped,If Other than Above 2 Address CC ILLI n' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 09/22/2021 Registrar of Vital Statistics Cynthia Bardin(ECectronicalfy signed) (signature) District Number 5762 Place Kingsbury Town, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: II-- //� Z Date of Disposition I(73114 Place of Disposition tMJL [r«.-a rw- ILI a (address) W CCCC (section) (lot number) (grave number) SName of Sexton or Person in Charge of Premise Z (p se print) /� W Signature Title ` free DOH-1555(07/18)p 1 of 2 ci 37 Public Health Law Sec. 4145(2b) Receipt Human remains of r Fes; delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# 1 -L=