Romer, Gladys NEW YORK STATE DEPARTMENT OF HEALTH I
Vital Records Section 't - _ '� L
Burial - Transit Permit 11
+4 Name First Middle Last Sex
0 Gladys Gertrude Romer Female
Date of Death Age If VeteranofU.S. Armed Forces,
1- November 5. 2006 86 War or Dates
Z Place of Death Hospital, Institution or
W City, Town, or Village Fort Edward Street AddressFoRT HUDSON HEALTH CARE FAC.
G Manner of Death x❑ Natural Cause ❑ Accident ❑ Homicide 0Suicide ❑ Undetermined D Pending
W Circumstances Investigation
(J Medical Certifier Name Title
W PHILIP J GARA u's' MD
0 Address
327 Broadway, Fo. Edward, NY 12828
4. Death Certificate Filed District Number Register Number 5/-,
i City, Town or Village Fort Edward —
�7.5-5 's
Date Cemetery or Crematory
❑ Burial November 10. 2006 Pine View Crematorium
Address
El Cremation Quaker Road Oueensburv, NY 12804-
Date Place Removed
a ❑ Removal and/or Held
- and/or Address
Hold
V) Date Point of
4 0 Transportation Shipment
d by Common Destination
0 Carrier
Date Cemetery Address
0 ❑ Disinterment
Reinterment Date Cemetery Address 1:1
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00283
Address
F 68 Main St., P. O. Box 67, Hudson Falls, New York 12839
2 Name of Funeral Firm Making Disposition or to Whom
i Remains are Shipped, If Other than Above _
W Address
O.
Permission is her by granted to dispose of the human remain scribed abov as indicated.
Date Issued // 7 lJ(� Registrar of Vital Statis .cs '
signa u
District Number Place Fort Edward,New York
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
w Date of Disposition t I-#3- o(o Place of Disposition tom;ne v;Q d CI wta or,'v c•-+
w (address)
N
0 1 (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises t h(please prin..,disti iZt- ne/%
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w Signature Title e_eN-+K-4ar7 ri55'i