Gaulin, Carolyn NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Carolyn Sue Gaulin Female
Date of Death Age If Veteran of U.S. Armed Forces,
January 22, 2015 68 War or Dates
F Place of Death Hospital, Institution or
wT City, Town or Village Glens Falls Street Address Glens Falls Hospital
uiCk Manner of Death 0 Natural Cause 0 Accident 0 Homicide 0 Suicide FlUndetermined El Pending
Circumstances Investigation
a-, Medical Certifier Name Title
Ck Michael Miles, M.D
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village 5601 L-f 3
®Burial Date Cemetery or Crematory
k,, January 27, 2015 Pine Viewc Cemetery
❑Entombment Address
0Cremation
1� Date Place Removed
z Removal and/or Held
and/or
E. Hold Address Pine Viewc Cemetery
t/? Date Point of
Shipment
�
�:; Transportation
by Common Destination
0 Carrier
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
hRemains are Shipped, If Other than Above
Address
te
rei
7" Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued - / Z fj / / 5 Registrar of Vital Statistics U) C lia
(signature)
District Number 5601 Place 6 S V-I \ c 1 Co J
. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
M
vi'
t� Date of Disposition 01/27/2015 Place of Disposition 21 Quaker Rd, Queensbury, NY 12804
a` (address)
itt Erie 76E 1
(section) (lot number) (grave number)
la
0 Name of Sextnn or Person in Charge of Premises Connie Goedert
(please print)
,2 (pv Cemetery Superintendent
LiIY Signatur .f�11-,tc Title
i (over)
DOH-1555 (02/2004)