Gori, Patricia L. f
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Patricia L God Female
Date of Death Age If Veteran of U.S.Armed Forces,
04/27/2020 59 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Lake Luzerne Town Street Address 63 Lake Ave Apt.3,Lake Luzeme Town,New York 12846
W
C) Mannerof Death Natural Cause Accident Homicide Suicide Undetermined ❑Pending
V Circumstances Investigation
W Medical Certifier Name Title
Thomas Portuese MD
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Lake Luzerne 5656
Burial Date Cemetery,Crematory or Facility Name
04/28/2020 Pineview Crematory
Entombment Address
mu-
Cremation Queensbury Town,New York
❑Donation
ZO Removal Date Place Removed
and/or and/or Held
~ Hold Address
N
O
a Date Point of
W Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
--[Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home Inc 00448
Address
7 Sherman Ave,Corinth,New York 12822
Name of Funeral Firm Making Disposition or to Whom
�— Remains are Shipped,If Other than Above
Address
Q
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/28/2020 Registrar of Vital Statistics Cynthia Sherwood(Electronically Signed)
(signature)
District Number 5656 Place Lake Luzerne, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H
Z Date of Disposition y -Zj Zp Place of Disposition
2 (a dress)
W
N (section) I (lotnumber) /gravenumber)
M n(
0 Name of Sexton or Person in Charg f Premises M
Z /p ase print)
W Signature Title
DOH-1555(o7/18)p 1 of 2
Public Health Law Sec. 4145�22b) - �1
Receipt
Human remains of delivered on , 20 T
Pine View Cemetery Repfesenting the funeral home named on burial permit
,Official Funeral Directors Reg.or License#
1