Patten, Carole Jane �r vt L .:.1) . 133
NEW YORK STATE DEPARTMENT OF HEALTH .\\,.`� Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Carole Jane Patten Female
Date of Death Age If Veteran of U.S.Armed Forces,
09/12/2022 83 Years War or Dates
H Place of Death Hospital,Institution or
WCity,Town or Village Elizabethtown Town Street Address Essex Center For Rehabilitation And Healthcare
p Manner of Death I1 Natural Cause IllAccident []Homicide []Suicide Undetermined El Pending
W Circumstances Investigation
V W Medical Certifier Name Title
C Mikram Jafri MD
Address
81 Park Street,Elizabethtown Town,New York 12932
Death Certificate Filed Town Of Elizabethtown District Number Register Number
City,Town or Village 1552 77
HBurial Date Cemetery,Crematory or Facility Name
09/15/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
Z❑Removal Date Place Removed
and/or and/or Held
~ Hold Address
N
0
Date Point of
(/) Transportation Shipment
Q by Common __---
Carrier Destination
Date Cemetery Address
Disinterment
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078
Address
136 Main St,S Glens Falls, New York 12803
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped,If Other than Above
2 Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/15/2022 Registrar of Vital Statistics Janet E Cross(E(ectronicalry Signed)
(signature)
District Number 1552 Place Town Of Elizabethtown
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—Z Date of Disposition ail ISM, Place of Disposition e nw�
W /address)
W
N (section) (lot number) (grave number)
LIC
7
GName of Sexton or Person in Charge of Pr ' es /p!g e print)
Z CefinviZit
W Signature Title
DOH-1555(o7/18)p 1 of 2
•
07,
Public Health Law Sec. 4145(2b)
I
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg. or License#