Gondella, Ruth 30 5
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Ruth M.Pasco Gondella Female
Date of Death Age If Veteran of U.S. Armed Forces,
June 12,2011 98 War or Dates
i.. Place of Death Hospital, Institution or
Z City, Town or Village Palatine Bridge Street Address Palatine Nursing Home
pManner of Death Natural Cause n Accident n Homicide Suicide Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
G Lawerence Lerner Dr.
Address
7 Timmerman Ave.,St.Johnsville,NY 13452
Death Certificate Filed District Number Register Number /
City, Town or Village Palatine Bridge,NY 2827
❑Burial Date Cemetery or Crematory
Entombment June 13,2011 Pineview Crematory
Address
®Cremation Queensbury,NY
Date Place Removed
ZO n Removal and/or Held
and/or Address
L' Hold
N
O Date Point of
O n Transportation Shipment
p by Common Destination
Carrier
Date Cemetery Address
n Disinterment
n Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Houghtaling& Smith Funeral Home,Inc. 00950
Address
20 Otsego Street,Canajoharie,NY 13317
Name of Funeral Firm Making Disposition or to Whom
F_ Remains are Shipped, If Other than Above
• Address
Ct
Permission is hereby granted to dispose of the human re ain scribedove s i sated.
Date Issued L --./3 - I / Registrar of Vital Statistics - ---
(signature)
District Number d,f,,? 7 Place Palatine Bridge,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
/�
tu• Date of Disposition b-lb-li Place of Disposition `�Vct�J C +w*c-(vtri.„..
(address)
W
fY
(section) // 11 (lot n(�'er) (grave number)
pName of Sexton or Pers in Charge Premises h Artt
W (please print)
Signature -- Title (Vit h JR-CI
(over)
DOH-1555(02/2004)