Godfrey, Mary NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Mary Jane Godfrey Female
<I Date of Death A e If Veteran of U.S. Armed Forces,
:,i,ii July 04, 2017 dor 07R2 War or Dates n/a
Place of Death Hospital, Institution or
M City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death lNatural Cause 0 Accident 0 Homicide 0 Suicide r7Undetermined ri Pending
Circumstances Investigation
11 tu Medical Certifier Name Title
Thomas Portuese MD.
Address
100 Broad St. , Glens Falls, NY. 12801
Death Certificate Filed District Number Register Number
``> City, Town or Village Glens Falls 5601 1 6 ►
Date Cemetery or Crematory
❑Burial July 05, 2017 PineView Crematorium
Address
El Cremation Quaker Rd. , Queensbury, NY. 12804
Date Place Removed
Removal and/or Held
.•.Li and/or Address
�' Hold
Oh
Q Date Point of
N0 Transportation Shipment
E by Common Destination
Carrier __
Disinterment Date Cemetery Address
Reinterment Date _ Cemetery Address
gi Permit Issued to Registration Number
>` Name of Funeral Home Mason Funeral Home 01117
ig Address
18 George St. , PO. Box 277, Fort Ann, NY. 12827
<' Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
iiiiii Permission is hereby granted to dispose of the human remains described above as indicated.
I Date Issued 7/05/1 7 Registrar of Vital Statistics (./0 V
5 (signature)
iiiiiiiii
District Number
5601 Place City of Glens Falls, NY.
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F pp
I, Date of Disposition ,/"I f Place of Disposition 1i`nt'i- (r 1°'''—'
(address)
W
to
CC (section) (lot number)(' (grave number)
0 Name of Sexton or Person in Charge of Premises r„ I.'-1W
z (please print)
Signature ii -x Title Ci-P
(over)
DOH-1555 (9/98)