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Hummel, Cynthia S
# 3y 110F NEWYORKSTATEDEPARTMENTOFHEALTH Permit Burial - Transit Bureau of Vital Records Name First Middle Last Sex Cynthia S.Hummel Female Date of Death Age If Veteran of U.S.Armed Forces, 05/08/2022 64 Years War or Dates Place of Death Hospital,Institution or WCity,Town or Village Hudson Falls Village Street Address 31 Hunt Avenue,Hudson Falls Village,New York 12839 ey Manner of Death LI Natural Cause Accident Homicide Duicide FlUndetermined ❑Pending W Circumstances Investigation W Medical Certifier Name Title 0 Ageel Gillani MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed Village Of Hudson Falls District Number Register Number City,Town or Village 5726 26 Burial Date Cemetery,Crematory or Facility Name 05/10/2022 Pine View Crematorium Entombment Address Cremation Queensbury Town,New York Donation Date Place Removed © Removal and/or Held I— and/or N Hold Address 0 Date Point of ()❑Transportation Shipment Q by Common Carrier Destination Disinterment Date Cemetery Address Disinterment 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 H Remains are Shipped,If Other than Above 2 Address OC ttt a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/10/2022 Registrar of Vital Statistics Cynthia Barcfin(ECectronicaffySigned) (signature) District Number 5726 Place Village Of Hudson Falls I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:e /�,� WDate of Disposition 5-'It I it Place of Disposition /a'i .,.,.v `-'�` W CD CC !ot n tuber/ . .,,,....,it (grave number) (section) (� N gName of Sexton or Person in Charge of Premises / rt 1(,I f.•print/ l `t .,�,a 2. z W Signature CJ\ s Title f� (Vc DOH-1555(07/18)p i of 2 e..? i. t.. 0 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#