Vantassell, Catherine Vivian NEW YORK STATE DEPARTMENT OF H EALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Catherine Vivian VanTassell Female
Date of Death Age If Veteran of U.S.Armed Forces,
01/25/2023 76 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death Undetermined Pendin
W Natural Cause Accident Homicide Suicide g
U Circumstances Investigation
ui Medical Certifier Name Title
C3 Kelly Maley PA
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 56
X Burial
M Date Cemetery,Crematory or Facility Name
02/01/2023 Pine View Cemetery
Entombment Address
[]Cremation Queensbury Town, New York
Donation
OZ ElRemoval Date Place Removed
and/or
N and/or Held
H Hold Address
0
a- Date Point of
N[]Transportation
p by Common Shipment
Carrier Destination
O
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
f_ Remains are Shipped,If Other than Above
Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/30/2023 Registrar of Vital Statistics Megan Nohin(Electronically Signed)
(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:
H
Z Date of Disposition off. t. D 3 Place of Disposition 0\ 01_Lck<e. 1a�',c;UJ
2 (address) I
W \ ic.rn 1E
N
CC (sect; (lot number) (grave number)
O Name of Sexton or Person in Charge of Premises C on re �1�"CJCJ
Z _ w (please print)i
Ill Signature
I�C Y.4.
Title �i a/ I�i r -7 i? at
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 012966
Receipt
Human remains of t - delivered on. ( _ , 20.
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
VANTASSEL
NAME Catherine VanTassell Age:76
Lot Owner: Jordan Dougher
Lot# Horicon 41 E Grave# 1
Case: Concrete
Died: 1 .2 5.2 3 Interred: 2 . 1 .2 3
Funeral Home: Carleton FH
Cemetery: Pine View
DOUGHER
Owner
Jordan Dougher
Address Plot
6 Dream Lake Rd. Oueenshury, NY 12804 Horicon
Phone # Lot #
518-603-5513 41E
Deed # Date
4368 1 .26.23
Cost Foundation Y - N
$700.00
Location West-Madison
East-Vacant
North-Vacant
South-Vacant
Remarks
I ACKNOWLEDGE THE RECEIPT OF THE RULES AND REGULATIONS OF THE
PINE VIEW CEM TERY:
SIGNATURE: DATE: ' �1 ) rDJ
SIGNATURE: DATE:
Record of Interments
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