Barrett, Lois Verna NEW YORK STATE DEPARTMENT OF HEALTH ; __A,/ Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Lois Verna Barrett Female
Date of Death Age If Veteran of U.S.Armed Forces,
12/30/2022 89 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Whitehall Village Street Address 8 Elizabeth Street Apt 210,Whitehall Village,New York 12887
p Manner of Death El Natural Cause Accident Homicide ESuicide r1Undetermined El Pending
W C) "Circumstances Investigation
W Medical Certifier Name Title
0 Ashley Saville NP
Address
,g Ca
,, rey Road,Queensbury Town,New York 12804
Death Certificate Filed Village Of Whitehall District Number Register Number
City,Town or Village 5728 20
Burial Date Cemetery,Crematory or Facility Name
01/04/2023 Pine View Crematorium
Entombment Address
Cremation Queensbury Town,New York
Donation
ZO❑Removal Date Place Removed
and/or and/or Held
F Hold Address
N
0
IL Date Point of
N❑Transportation Shipment
p by Common
Carrier Destination
T
Disinterment
Date Cemetery Address
ID
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
H 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 01/04/2023 Registrar of Vital Statistics Patti Gordon(E(ectronica1Ty Signed)
(signature)
District Number 5728 Place Village Of Whitehall
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W I—
Date of Disposition //ZZ0Z5 Place of Disposition 6 V (7G>� Cr.0rr14,�a Ili
(address)
W
N (section) (lot numbe) 1 (grave number)
CC
c,0 Name of Sexton or Person in Charge o emises I '11�ir�o'�r J\ i ( /
Z
(please print)
rr
W Signaturesid Title 6�rJ�f�`t12'
DOH-1555(07/18)p 1 of 2
f Y4
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#