Wornall, Barbara Mae rn
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Barbara Mae Wornall Female
Date of Death Age If Veteran of U.S.Armed Forces,
06/27/2022 92 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Moreau Town Street Address 198 Bluebird Road,Moreau Town,New York 12803
p Manner of Death EINatural Cause Accident Homicide Suicide Undetermined ❑Pending
W Circumstances Investigation
W Medical Certifier Name Title
CI Anne Evans DO
Address
3 Irongate Center,Glens Falls,New York 12801
Death Certificate Filed Town Of Moreau District Number Register Number
City,Town or Village 4562 38
Burial Date Cemetery,Crematory or Facility Name
OEM 06/29/2022 Pine View Crematorium
Entombment Address
Cremation Queensbury Town,New York
Donation
o❑Removal Date Place Removed
and/or and/or Held
H Hold Address
O. Date Point of
co Transportation
by Common Shipment
Carrier Destination
EIDisinterment Date Cemetery Address
❑Reinterment
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
Remains are Shipped,If Other than Above
'2 Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/29/2022 Registrar of Vital Statistics Leeann Mc ca&e(ECectronica1CySigned)
(signature)
District Number 4562 Place Town Of Moreau
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F—
W Date of Disposition -3p—r zj Place of Disposition P�` ,j e vie„) C e„,,Seci.{
LU (addr
W
N (section) aft (grave number)
j
8 Name of Sexton or Person in Charge Prem. s �a Km, ✓�+ t r
Z (please print)
W Signature Title Q��S
DOH-1555(07/18)p i 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#