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Van Guilder, Rebecca le a NEW YORK STATE DEPARTMENT OF HEALTH ` ' (�� Vital Records Section Burial - Transit Permit Name First Middle Last Sex woor Rebecca Sue Van Guilder Female v Date of Death Age If Veteran of U.S. Armed Forces, February 21, 2017 59 War or Dates Place of Death Hospital, Institution or City, Town or Village Town of Northumberlan Street Address 421- Manner of Death Undetermined Pending 0 Natural Cause Accident Homicide Suicide ❑Circumstances Investigation 1F Medical Certifier Name Title KATHLEEN KONDO, Address 0,14 990 Rte 67 Ballston Spa, NY 12020 to Death Certificate Filed ,� District Number Register tuber "v City, Town or Village co owNLex\an c"�lc, k❑Burial Date Cemetery or Crematory February 23, 2017 Pine Vew Crematorium ❑Entombment Address ot,r©Cremation Date Place Removed Removal aand/or and/or Held Hold Address ItiDate Point of Transportation Shipment by Common Destination 0 Carrier Porr Disinterment Date - Cemetery Address 0 Reinterment Date Cemetery Address 540 Permit Issued to Registration Number tmrr Name of Funeral Home Carleton Funeral Home, Inc. 00281 ot 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 ,P Remains are Shipped, If Other than Above 2' Address Permission is hereby granted to dispose of the human ins described above as indicated. Date Issued Q a3 117 Registrar of Vital Statistics'fi e , ' I (signatu District Number l ltcj Loa Place TOk¢c`(—) 0- (© Y' 0 cY1 17-eAr I '.aYTh A s I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 02/23/2017 Place of Disposition ";,kl,-✓ rm je i— (address) iik (section) iyot number) ( (grave number) 09 Name of Sexton or Person in Charge of Pr mises / r„{ J r44 it (please print) tuk Signature El Title o�mlr i�t, (over) DOH-1555 (02/2004)