Goodale Sr., Hollis NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle
Last Sex
:1: Hollis C. Goodale,Sr. Male
:rr i Date of Death Age If Veteran of U.S. Armed Forces,
March 31, 2015 82 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Hudson Falls Street Address 51 Feeder Street
Manner of Death X Natural Cause n Accident I r Homicide Suicide Undetermined Pending
Circumstances Investigation
S Medical Certifier Name Title
. ; Thomas Coppens,MD
;; ? Address
: 3 Irongate,Glens Falls,NY 12801
K? Death Certificate Filed District Number _ Register Number
aCity, Town or Village Hudson Falls,NY 5 I a
❑X Burial Date Cemetery or Crematory
❑Entombment April 6,2015 Pine View Cemetery
Address
❑Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
�' Hold
N
O Date Point of
NI Transportation Shipment
a by Common Destination
Carrier
n Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
:r Permit Issued to Registration Number
:::: Name of Funeral Home Regan Denny Stafford Funeral Home 01443
,:
r::: Address
53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
$+ Remains are Shipped, If Other than Above
2 Address
1
rj Permission is hereby granted to dispose of the human remains described above as indicated.
•
j▪ - ,/
{ Date Issued 7 d -1S'Registrar of Vital Statistics t o W
(signature)
:KDistrict Number , 7 2 Place Hudson Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition 4/6/201 5 Place of Disposition 21 Quaker Road, Queensbury, NY 1 2804
2 (address)
tu
Mohawk 32 2
Ct
(section) (lot number) (grave number)
p• Name of Se n or Person in Charge of Premises Connie L. Goedert
Z (please print)
W
Signature,/ V!-di-ck !ti - Title Cemetery Superintendent _
(over)
DOH-1555(02/2004)