Kline, Dianne Marie zd
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Dianne Marie Kline Female
Date of Death Age If Veteran of U.S.Armed Forces,
01/05/2022 62 Years War or Dates
F. Place of Death Hospital,Institution or
111
City,Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause El Accident 0 Homicide 0 Suicide El Undetermined ❑Pending
W Circumstances Investigation
V
W Medical Certifier Name Title
0 Christopher Smith MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 12
❑Burial Date Cemetery,Crematory or Facility Name
01/07/2022 Pine View Crematorium
❑Entombment Address
lCremation Queensbury Town,New York
❑Donation
Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
d Date Point of
Lb ❑Transportation
by Common Shipment
Carrier Destination
0 Disinterment
Date Cemetery Address
Date Cemetery Address
❑Reinterment
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
"S Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/06/2022 Registrar of Vital Statistics MeganWblin(ECectronicalTySigned)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H
Z Date of Disposition ( 1 10 In_ Place of Disposition
2 (address)
W
CC N (section) Allot number) (grave number)
aName of Sexton or Person in Charge remises �iS � �►.[
Z f/ (pleas print/ y�
W
Signature L� Title CW'M0IVL
DOH-1555(07/18)p 1 of 2
rr `;•
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on ' , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#