VanDusen, Gertrude NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
T Name First Middle Last Sex
C Gertrude VanDusen Female
ril D• ate of Death Age If Veteran of U.S. Armed Forces,
J• uly 17,2013 92 War or Dates
Place of Death Hospital, Institution or
{ City, Town or Village Queensbury Street Address Westmount Health Facility
Manner of Death1-1 I XI Natural Cause n Accident El Homicide E Suicide n Undetermined n Pending
Circumstances Investigation
t. .
Medical Certifier Name Title
i. Roslyn Socolof,MD
_0: Address
Queensbury,NY
Death Certificate Filed District Number Reer Number
City, Town or Village Queensbury,NY 5657
El Burial Date Cemetery or Crematory
July 23, 2013 Pine View Cemetery
D Entombment Address
❑Cremation Quaker Road, Queensbury, ,NY 12804
Date Place Removed
z C Removal and/or Held
2 and/or Address
t"' Hold
U)
O Date Point of
N 7-1
Li Transportation Shipment
p by Common Destination
Carrier
I I Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
i',I: Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
i11'r, Remains are Shipped, If Other than Above
Address
_ Permission is hereby granted to dispose of the human remains describedsc� bove as indicated.
-j1 � 9 �(Date Issued ll60) e istrar of Vital Statistics
,_________________
(signature)
District Number 5657 Place Queensbury,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 7•/23•/1• 3 Place of Disposition Pine View Cemetery
W (address)
N Huron 13 A 2
IY (section) (lot number) (grave number)
pName of Sex n or Person in Charge of Premises Connie L. Goedert
Z ,/, G /� (please print)
W Signature 7�.. .� `J'`,'"„rl Title Superintendent
(over)
DOH-1555(02/2004)
VanDusen Lot No. 24 A
Address R .D. Tl, aunnyside rd. . Glens_Falls, T .Y: Section No. 2
Plot ulldson
Owner Plot
VenDus-.,
Date June 3, 1970
200 Superficial ft. @ 41.50 per s q. ft .
Location Bounded on the T?otth by Pond, East by Vacant, south by lot of Read,
',Test by Path.
Corner Posts
'Remarks
Deed No. (and changes) 1146
Payment Record Paid in full June 3. 1970
_ Lo3 _ �,1-:/sn '
6
3s59
N-
Form No. 01
Record of Interments
Linda Van Dusen 12/28/02 5
Gertrude D. VanDusen 4/2/02 6
Sidney Hall Van Dusen 3/15/89
t�o� V� t BSc ,� -1'o r a� N 8
TO/VP ;)I
/O /-
I j
6 I
X
NAME VAN DUSEN, GERTRUDE
Age: 92
Cause: Natural
Lot Owner: John B. & Gertrude Van Dusen
Lot # 13 A Huron
Grave #2
Case # Concrete
Died: 7-17-2013
Interred: 7-23-2013
Undertaker: Regan, Denny & Stafford