Gutekunst, Dorothy NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit1Permit
Vital Records Section
Name First Middle Last Sex
Dorothy Virginia Gutekunst Male
Date of Death Age If Veteran of U.S. Armed Forces,
June 5, 2011 85 War or Dates
F"- Place of Death Hospital, Institution or
W City, Town or Village Glens Falls Street Address Glens Falls Hospital
0 Manner of Death Natural Cause Accident Homicide Suicide Undetermined Pending
WW Circumstances Investigation
W Medical Certifier Name Titl 4.
e
3' Farhana Kamal MD,
Address
Glens Falls Hospital Glens Falls, NY 12801
Death Certificate Filed District Number, Reg ist IXut�gber
City, Town or Village o��°j �(
❑Burial Date Cemetery or Crematory
June 7, 2011 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z El Removal and/or Held
0 and/or Address
t-= Hold Pine View Crematorium
GO Date Point of
Transportation Shipment
Q by Common Destination
L Carrier
ElDisinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00276
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
2 Address
W`{
a'' Permission is he eby granted to dispose of the human remains described above as indicated.
Date Issued 5/ 'Nall Registrar of Vital Statistics (1 -)GL4-\k. UQ
�,,/� /�( �I� (signature)
District Number �"/ Place �/e43 j"�G 'i�'V Pgr/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W_ Date of Disposition (o /5 I t 1 Place of Disposition Pi n[U Ct- Crw-sto rt.,
2 f (address)
W
(I)
iX (section) (lot umber) (grave number)
in Name of Sexton or P on in Charg of Premises 3 (c r" `'t
ase print)
W Signature Title lkc(d�
(over)
DOH-1555 (02/2004)