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Dodge, Constance Fay NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Constance Fay Dodge Female Date of Death Age If Veteran of U.S.Armed Forces, 08/31/2023 78 Years War or Dates Place of Death Hospital,Institution or WCity,Town or Village Fort Ann Town Street Address 367 Buttermilk Falls Road,Fort Ann Town,New York 12827 p Manner of Death ❑X Natural Cause DAccident El Homicide 0Suicide FlUndetermined El Pending LU Circumstances Investigation W Medical Certifier Name Title G John Aiken Coroner Address 40 Burquist Road,Fort Ann Town,New York 12827 Death Certificate Filed Town Of Fort Ann District Number Register Number City,Town or Village 5754 12 Burial Date Cemetery,Crematory or Facility Name 09/01/2023 Pine View Crematorium Entombment Address ©Cremation Queensbury Town,New York Donation ❑Removal Date Place Removed and/or and/or Held H Hold Address 0 10. Date Point of Cl) Transportation Shipment Q by Common 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 Remains are Shipped,If Other than Above M Address Q LU O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 09/01/2023 Registrar of Vital Statistics Mt-antra flferringskaw(ECectronicatTy Signed) (signature) District Number 5754 Place Town Of Fort Ann I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition I 1117,9 Place of Disposition <PALILJ (address) W CC N (section) ,p/ llnuc ber) (grave number) 0 Name of Sexton or Person in Charge Premises Z (please print)�^ W Signature Title ( mtt 134 DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) ' ` 2" / P -.„., Receipt 1 Human remains of _ delivered on , 20 i Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg. or License#-