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Middleton, Helen A
• NEW YORK STATE DEPARTMENT OF HEALTH - m Bureau of Vital Records BurialTransit Perm Name First Middle Last Sex Helen A.Middleton Female Date of Death Age If Veteran of U.S.Athied Forces, 02/11/2022 88 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing ILI p Manner of Death © Natural Cause ❑Accident ❑ Homicide ❑Suicide ❑Undetermined ❑ Pending WI."- Circumstances Investigation W Medical Certifier Name Title CI Roslyn Socolof MD Address 42 Gurney Ln,Queensbury Town,New York 12804 Death Certificate Filed t District Number Register Number City,Town or Village Queensbury 5657 o 36 ❑ Burial Date Cemetery,Crematory or Facility Name 02/15/2022 Pine View Crematorium ❑ Entombment Address X❑Cremation Queensbury Town, New York O Donation ZZ• Removal Date Place Removed and/or and/or Held ~ Hold Address CO a d Date Point of CO Li Transportation p by Common Shipment Carrier Destination El Disinterment Date Cemetery Address Reinterment Date Cemetery Address Perm:li 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 H Remains are Shipped,If Other than Above 5 Address C W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/15/2022 Registrar of Vital Statistics Caroline Jfildegarde Barber(Electronically Signed) (signature) District Number 5657 Place Queensbury, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I— 1 ' � Z Date of Disposition 2-lite Ill- Place of Disposition kv4.- 6-onv..._- w 2 (address) W (C (section) (lot number) (grave number) ( Name of Sexton or Person in Charge of Premise Z 4' . please print) LU Signature Title � � DOH-1555(o7/18)p 1 of 2 • ` V,Yn $4 9 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#