Staunches, Helen Louise 0 # sts
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NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Helen Louise Staunches Female
Date of Death Age If Veteran of U.S.Armed Forces,
07/11/2022 78 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation
p• Manner of Death a Natural Cause Accident []Homicide Suicide Undetermined []Pending
Circumstances I 'Investigation
WMedical Certifier Name Title
O Courtney Diamond NP
Address
170 Warren St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 361
Burial Date Cemetery,Crematory or Facility Name
07/15/2022 Pine View Crematorium
[]Entombment Address
Cremation Queensbury Town,New York
Donation
Removal Date Place Removed
521 and/or and/or Held
Fr) Address
0
n- Date Point of
U)❑Transportation
p by Common Shipment
Carrier Destination
[]Disinterment
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
l-- Remains are Shipped,If Other than Above
5 Address
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/13/2022 Registrar of Vital Statistics Megan Noun(ECectronica1Ty Signet°
(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:
F—
Z Date of Disposition ")Ili l2.Z. Place of Disposition
2 (address)
LU
N
CC (section) Om number) (grave number)
• Name of Sexton or Person in Cha of Premises !� s Mtil
Z
(pie e print)
W Signature Title (PM" r
DOH-1555(07/18)p i of 2
CI 1
Public Health Law Sec. 4145(2b)
Receipt
•
Human remains of delivered on , 20
Pine View Cemetery Representing thefuneral home named on burial permit
Official Funeral Directors Reg.or License#