Vestal, Female NEW YORK STATE DEPARTMENT OF HEALTH � Burial Records Section - Transit Permi
NO Name First Middle Last Sex
Female Vestal Female
igi Date of Death Age If Veteran of U.S. Armed Forces,
12/28/10 War or Dates
t Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address
&LI Glens falls Hospital
0 Manner of Death ► Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Fending
C?in F al Demise
Circumstances Investigation
1E Medical Certifierame Title
O. Claudia Gerten CNN
Address
90 South Street Glens Falls , NY
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 17
❑Burial Date Cemetery or Crematory
Ni
❑Entombment 12/29/10 Pine View C,rematurium
Address
it®Cremation Queensbury, NY
Date Place Removed
❑Removal and/or Held
and/or
E; Address
E
Cl) Hold
0 Date Point of
tti❑Transportation Shipment
Q by Common Destination
Carrier
❑Disinterment Date Cemetery Address •
mii❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Barton-McDermott Funeral Home , Inc. 00134
Address 9 Pine St Chestertown, NY
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
OZ
IU
r' Permission is hereby granted to dispose of the human remains described above as indicated..
Date Issued 12/29/10 Registrar of Vital Statistics CAm-T-.,31, _;,ip
(signature)
<< District Number 5601 Place Glens Falls, NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
III Date of Disposition re.. 3 Zoil Place of Disposition Pm4 /NJ an4 oetu�
iii
(address)
ilk
CC (section) (lo number) (grave number)
CV
its Name of Sexton or P r on in Ch rge of Premises C r•s oeko S th�,.,tI
7 1 (please print)
::<> Signature Title (ll 64109
(over)
DOH-1555 (02/2004)