Clear, Gloria NEW YORK STATE DEPARTMENT OF HEALTH -"` '` 1t ( 0
Vital Records Section Burial - Transit Permit
; Name First -Middle Last Sex
Gloria Ellen Clear Female
Date of Death Age If Veteran of U.S. Armed Forces,
June 13, 2018 90 War or Dates
tPlace of Death Hospital, Institution or
14
City, Town or Village South Glens Fags Street Address 28 Circle Drive
Manner of Death a Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
41-
Circumstances Investigation
W., Medical Certifier Name Title
0't Suzanne Blood, M.D. Dr.
mil Address
14 Manor Drive Queensbury, NY 12804 _
Death Certificate Filed District Number Register Number
City, Town or Village
❑Burial Date Cemetery or Crematory
June 18, 2018 Pine View Crematorium
• ❑Entombment
Address
• ®Cremation Quaker Road Queensbury,N412804 _,;46
Date Place Removed
❑ Removal and/or Held
0 and/or Address
,i.., Hold Pine View Crematorium
Otz Date' Point"of
wa❑Transportation Shipment
co by Common Destination
, 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 Fa , NY 12839
Name of Funeral Firm Making Disposition or to Whom
F Remains are Shipped, If Other than Above
Address
'W ,.
d. Permission is hereby ranted to dispose of the human rema" escribed abo a in icated.
x§g
Date Issued 4/t(/f Registrar of Vital Statistics
(signature)
District Number y5..19 Place Vt //t f t,Q�S Rik-
,
3 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
' Date of Disposition 06/18/2018 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
=LLI
,00
r (section) /'I (lot number) (grave number)
pName of Sexton or Person in Charge of Premises 1 Are. L �l„�
I!'
t lease print)
Signature ilt"-- Title llZfrr/TWR
(over)
DOH-1555 (02/2004)