VanGuilder, Patricia NEW YORK STATE DEPARTMENT OF HEALTH ' - .4" A c$b
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Patricia Joyce VanGuilder Female
Date of Death Age If Veteran of U.S. Armed Forces,
July 16, 2018 78 War or Dates
Place of Death Hospital, Institution or
uj City, Town or Village Queensbury Street Address 50 Main Street
CL Manner of Death nj Natural Cause 0 Accident 0 Homicide 0 Suicide 0 Undetermined 0 Pending
tij Circumstances Investigation
L Medical Certifier Name Title
Patricia Auer,
`` Address
Queensbury Hudson Headwaters Queensbury, NY 12804
Death Certificate Filed District Number Register Number
A: City, Town or Village 5L7,51 t l�?t
_°0 Burial Date 18, 2018 Cemetl F or Crematory
0 Entombment Address July e View Crematorium
Tf' ®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
0 Removal and/or Held
and/or Address
Hold Moss Street Cemetery
Date Point of
(L`tL"ElTrans Transportation P Shipment
): by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
4Permit 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
Address
L
11`' Permission is hereby granted to dispose of the human remains described above as indicated.
l' g. Registrar of Vital Statistics -1NAR.
Date Issued 7—(�'- a0( 9 -- - Q. ir ;�
(signature)
District Number .5lP ji Place Qv 4t.t AS b of
! I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 07/18/2018 DispositionQueensbury,NY p Place of Quaker Road Queensbu NY 12804
(address)
Ur
CO
IX (section) ,l/ (lot number) (grave number)
-be Name of Sexton or Person in Charge o Premises /I�lb .5�,44p
Z I ( lease print)
.' Signature [ fain 9 Title � �" (L
(over)
DOH-1555 (02/2004)