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Carlton, Lois Ann 4- I14 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Lois Ann Carlton Female Date of Death Age If Veteran of U.S.Armed Forces, 02/17/2022 84 Years War or Dates Place of Death Hospital,Institution or $ City,Town or Village Albany Street Address Teresian House Nursing Home Co Inc U Manner of Death Undetermined ❑Pending G ©Natural Cause Accident Homicide Suicide Circumstances Investigation WG Medical Certifier Name Title Jacqueline Camuglia NP Address 200 Washington Ave Extention,Albany,New York 12203 W- Death Certificate Filed District Number Register Number City,Town or Village Albany 0101 0476 ElBurial Date Cemetery,Crematory or Facility Name 02/22/2022 Pine View Crematory Entombment Address ElCremation Queensbury Town,New York ❑Donation �: Date Place Removed z ❑Removal and/or and/or Held N Hold Address 0 CCD 1-1 Transportation Date Point of CI Common Shipment Carrier Destination Disinterment Date Cemetery Address ElReinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078 Address 136 Main St,S Glens Falls,New York 12803 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above Address EC W n' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/22/2022 Registrar of Vital Statistics 'DanieCCe S GiCCespie(ECectronica1TySigned) (signature) District Number 0101 Place Albany, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition 2/LTA 12 Place of Disposition (address) W U (C (section) (lot number) (grave number) Name of Sexton or Person in Charge o miles �1 M ii4t1 (p/e print) Signature Title pppp►►►► Crf DOH-1555(o7/i8)p t of 2 J I 5 A 07 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#