Holman, June Lorraine `/
NEW YORK STATE DEPARTMENT OF HEALTH LF Burial - Transit Permi
Bureau of Vital Records
Name First Middle Last Sex
-June Lorraine Holman Female
Date of Death Age If Veteran of U.S.Armed Forces,
05/30/2022 75 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death ❑ ❑ ❑ ❑Undetermined �Pendin
� Natural Cause Accident Homicide Suicide g
W Circumstances Investigation
V
WG Medical Certifier Name Title
Mathew Varughese DO
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 300
Burial Date Cemetery,Crematory or Facility Name
06/03/2022 Pine View Crematorium
Entombment Address
Cremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
O. Date Point of
N Transportation
3 by Common Shipment
Carrier Destination
ODisinterment Date Cemetery Address
ElReinterment 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
j Remains are Shipped,If Other than Above
Address
Q
W
a. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/02/2022 Registrar of Vital Statistics Megan Nolin(E(ectronically Signed)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I— �
Z Date of Disposition 4-y`ypzz Place of Disposition PI de I' (r. k6
ILI
2 (address)
W
Cl)OC (section) (l number) (grave number)
8 Name of Sexton or Person in Charg f Premis �id ii'VD4)b 00171.)
Z // (please print)
tU Signature `4' Title leeN i
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of ' delivered on , 20
Pine View Cemetery Representing the funeral home named op burial permit
_ .
Official Funeral Directors Reg.or License# 1 '