Oudekerk, Gloria NEW YORK STATE DEPARTMENT OF HEALTH C1
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Gloria Mary Oudekerk Female
Date of Death Age If Veteran of U.S. Armed Forces,
July 15, 2016 76 War or Dates
Place of Death Hospital, Institution or
W City, Town or Village Glens Falls Street Address Glens Falls Hospital
C3 Manner of Death FriNatural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined El Pending
Circumstances Investigation
W Medical Certifier Name Title
CI Sean Bain, M.D. Dr.
Address
100 park St. Glens Falls, NY 12801
Death Certificate Filed District Number Re tteNumber
City, Town or Village 5601•
� '
0 Burial Date Cemetery or Crematory
July 20, 2016 Pine Vew Crematorium
❑Entombment Address
®Cremation Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
G and/or Address
rz Hold
Date Point of
❑Transportation Shipment
CO by Common Destination
15 Carrier
❑ Disinterment Date Cemetery Address
Date Cemetery Address
El Reinterment
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 Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
M Address
W
Permission is hereby granted to dispose of the human re ins de ribed ab ve as indi ated
Date Issued 1 Registrar of Vital Statistics � //'-f
(signature)
District Number 5601 Place � 57dyI certify that the remains of the decedent identified above were disposed of in accorwith this permit on:
W Date of Disposition 07/20/2016 Place of Disposition Queensbury,NY 12804
2 (address)
W.
co
ct (section) (lot number) (grave number)
p Name of Sexton or Person in Charge of Premises G `"w��-•- St.imitt
Z (please print)
W Signature Title C/Em } —
(over)
DOH-1555 (02/2004)