Gooden, Ernestine Lee NEWYORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Ernestine Lee Gooden 7Female
Date of Death Age If Veteran of U.S.Armed Forces,
01/03/2020 66 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Johnstown Town Street Address Fulton Center For Rehabilitation And Healthcare
p Mannerof Death Natural Cause Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
U
W Medical Certifier Name Title
13 Gregory O'Keefe MD
Address
847 County Highway 122,Johnstown Town,New York 12078
Death Certificate Filed District Number Register Number
City,Town or Village Johnstown 1754 2
❑Burial Date Cemetery,Crematory or Facility Name
01/13/2020 Pine View Crematory
Entombment Address
X❑Cremation Queensbury Town,New York
Donation
ZO Removal Date Place Removed
and/or and/or Held
~CO) Hold Address
dDate Point of
CO) ❑Transportation Shipment
p by Common
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
I
Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care Inc 00364
I
Address
402 Maple Ave,Saratoga Springs,New York 12866
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
Address
cr
Uj
a Permission is hereby granted to dispose of the human remains described above as indicated. j
Date Issued 01/13/2020 Registrar of Vital Statistics YVanry7fart(Electronicaf Syned j
(signature)
District Number 1754 Place
Johnstown, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: j
Z Date of Disposition 10 Place of Disposition afu.—
W
(address/
W
CO)
IX (section) C (lot numb (grave number)
13 Name of Sexton or Person in Charge of Premises ��1
Z ease print/
W Signature tT Title
DOH-1555(07/18)p t of z
I
Public Health Law Sec. 4145(2b) 0 13, 3 4
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing-tote funeral home named on burial permit
Official Funeral Directors Reg.or License#
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