Paladin, Lorna M III
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Lorna M Paladin Female
Date of Death Age If Veteran of U.S.Armed Forces,
01/30/2023 99 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
W
Manner of Death []Natural Cause []Accident []Homicide Suicide []Undetermined []Pending
I I (Circumstances !Investigation
W Medical Certifier Name Title
Cl John Quaresima MD
Address
319 Broadway,Fort Edward Town,New York 12828
Death Certificate Filed Town Of Fort Edward District Number Register Number
City,Town or Village 5755 13
[]Burial Date Cemetery,Crematory or Facility Name
01/31/2023 Pine View Crematorium
Entombment Address
{]Cremation Queensbury Town,New York
Donation
OZ❑Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
d. Date ' Point of
Cl)[]Transportation
p by Common Shipment
Carrier Destination
•
[]Disinterment
Date Cemetery Address
r Date Cemetery Address
I Reinterment
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
I— Remains are Shipped,If Other than Above
5 Address
Q
W
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/31/2023 Registrar of Vital Statistics Aimee L Mahoney(ECectronicaCCy Signed)
(signature)
District Number 5755 Place Town Of Fort Edward
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition 213 171 Place of Disposition �w
2 (address)
w
Q (section) 7 (lot number) (grave number)
gName of Sexton or Person in Charge emises /+ l(9
/please print/
II
W Signature Title )170/(
DOH-1555(07/18)p t of 2
Public Health Law Sec. 4145(2b) �t
Receipt
Human remains of delivered on , 20 -
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg. or License#