Goodall, Willamena NEW YORK STATE DEPARTMENT OF HEALTH # S 3 Z
Vital Records Section 4 Burial - Transit Permit
•
Name First Middle Last Sex
Willamena Herberdina Goodall Female
Date of Death Age If Veteran of U.S. Armed Forces,
October 23, 2011 90 War or Dates
l Place of Death Hospital, Institution or
W' City, Town or Village Glens Falls Street Address Glens Falls Hospital
WManner of Death mki Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
U Circumstances Investigation
MI Medical Certifier Name Title
Gamal Khalifa, M.D. Dr.
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District nbe®() Regis er N.ber
City, Town or Village
❑Burial Date Cemetery or Crematory
October 26, 2011 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
E Hold
Date Point of
jp ❑Transportation Shipment
V) by Common Destination
C1 Carrier
Date Cemetery Address
❑ Disinterment
❑ Reinterment Date Cemetery Address
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
2 Address
W
Permission is hereby granted to dispose of the human remains de r e ab a as ; ated.
Date Issued /D 16/2z(/ Registrar of Vital Statistics / �
/ _ (signature)
District Number SG,Q1 Place 67- ,,d ,47
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W', Date of Disposition i o in J h Place of Disposition ►. (I %J C�fvrrc f orly�
(address)
CO
'
(section) lot number) (grave number)
p Name of Sexton or Pers in Charge of remises /f( ,
T �rtYt'�
Z (pleaks print)
W Signature ��� Title ati ro)4 i 0�
g
(over)
DOH-1555 (02/2004)