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Glode, Mildred • NEW YORK STATE DEPARTMENT OF HEALTH 3IL Burial - Transit Permit Vital Records Section '— Name First Middle Last Sex Mildred Elizabeth Glode Female • Date of Death Age If Veteran of U.S. Armed Forces, June 16, 2011 91 War or Dates Place of Death Hospital, Institution or City, Town or Village Street Address Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending Circumstances Investigation Medical Certifier Name Title Abhinetri Pandula, Dr. �� M=F Address 325 Main Street Hudson Falls, NY 12839 Death Certificate Filed District1Vy.mbber Register Number City, Town or Village ❑Burial Date Cemetery or Crematory June 21, 2011 Pine View Crematorium ['Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed ❑ Removal and/or Held and/or Address Hold n e., Date Point of nTransportation Shipment by Common Destination { Carrier Date Cemetery Address El Disinterment I I 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 ° Remains are Shipped, If Other than Above Address Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued -�(pp j Registrar of Vital Statistics J• (signature) District Number (, Place q_kSLmf ILA din Q QJ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 4 ink In Place of Disposition eitu.Uaaw L i�`�,{o tciw- 4 (address) (lot numb (grave number) +� (section) number� r Name of Sexton or Per n in Charge f Premises } k /v1 (please print) Signature Tite I C2 ,rht tO& ..._,� (over) DOH-1555 (02/2004)