Goldy, Margaret NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Margaret Eileen Goldy Female
Date of Death Age If Veteran of U.S. Armed Forces,
February 11, 2017 97 War or Dates
Place of Death Hospital, Institution or
it City, Town or Village Glens Falls Street Address Glens Falls Hospital
WsManner of Death X❑Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
W Circumstances Investigation
W Medical Certifier Name Title
CI Stephen Perazzelli, M.D
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village 5 6 a ) i a C)
®Burial Date Cemetery or Crematory
Pine View Cemetery
❑Entombment Address
❑Cremation Quaker Rd. Queensbury,NY 12804
Date Place Removed
z
❑ Removal and/or Held
and/or Address
�,,: Hold Pine View Cemetery
Date Point of
a. ❑Transportation Shipment
CO by Common Destination
0 Carrier
Date Cemetery Address
III Disinterment
Date Cemetery Address
❑ Reinterment
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
I— Remains are Shipped, If Other than Above
21 Address
CC
W
EL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued . 113 f !-7 Registrar of Vital Statistics wC>,^. , w. "
t-" (signature
District Number 5 70 ( Place 6 (s?n/'S �3 1 15)N y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition 2/1 8/1 7 Place of Disposition Quaker Rd. Queensbury,NY 12804
(address)
W COSeneca 27C 2
(section) (lot number) (grave number)
Name •
of
' n or Person in Charge of Premises Connie L. Goedert
z:, (please print)
W Signatu • di t -F=B Title Pine View Cemetery
(over)
DOH-1555 (02/2004) 1
I