Weller, Janet Lee ),
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Janet Lee Weller Female
Date of Death Age If Veteran of U.S.Armed Forces,
06/21/2022 77 Years War or Dates
l~ Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address 8 Barton Place,Queensbury Town,New York 12804
W Manner of Death n [] n I—IUntleterminetl []Pendin 0 I 1 Natural Cause Accident I l Homicide I (Suicide I I I I g
W Circumstances Investigation
U
W Medical Certifier Name Title
O John Stoutenburg MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed Town Of Queensbury District Number Register Number
City,Town or Village 5657 102
H
Burial Date Cemetery,Crematory or Facility Name
06/27/2022 i Pine View Crematorium
Entombment Address
[]Cremation Queensbury Town,New York
IIIDonation
OZ❑Removal Date Place Removed
and/or and/or Held
H Hold Address
U)
0
d Date Point of
(/)illTransportation
p by Common Shipment
Carrier Destination
riDisinterment 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
E— Remains are Shipped,If Other than Above
"i Address
CC
W
d Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/22/2022 Registrar of Vital Statistics Caroline itifdegarde(Barber(6CectronicaCCy Signed)
(signature)
District Number 5657 Place Town Of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
r
111
• Date of Disposition ( 17Z. Place of Disposition ef7)(1"...'
2 (address)
w
Cl)CC (section) ,.)lot numbe \�-��� //i� (grave number)
O Name of Sexton or Person in Charge o remises Ofa `-- ` .�1
Zolease print)ti
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lu Signature � Title _ `PO `
DOH-1555(07/18)p f of 2
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# !r`