Gasper, Phyllis NEW YORK STATE DEPARTMENT OF HEALTH . . :� : ' ft
Vital Records Section n Burial - Transit ermit
Name First Middle Last Sex
Phyllis Louise Gasper Female
Date of Death Age If Veteran of U.S. Armed Forces,
August 17, 2011 82 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address 16 Orville Street
W Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑Undetermined ❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
W
David Foote Md,
Address
Rt 4 Hudson Falls, NY 12839
Death Certificate Filed District MO (j Re �rJ1umber
City, Town or Village U 1
0 Burial Date Cemetery or Crematory
August 19, 2011 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
{ and/or Address
E Hold Pine View Crematorium
Date Point of
a- ❑Transportation Shipment
Cl) by Common Destination
el Carrier
Date Cemetery Address
El Disinterment
Date Cemetery Address
❑ 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
Remains are Shipped, If Other than Above
2 Address
W'
d Permission is hereby granted to dispose of the human remains des i d boy s in t d.
Date Issued 4 g/, / // Registrar of Vital Statistics /�I'9�yt/ y
(signature)
r District Number SIC/ Place 4yyo 7�q
6. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I
wi Date of Disposition 1 1h(I( Place of Disposition P K� �J C tortiiw.
2 (address)
W'`
M (section) }} (lot number . (grave number)
0 Name of Sexton or Pers n in Charge of remises / r,iA' Kt✓ ^-t>f�
121-,,,t,_ � (please print)
SignatureTitle dit t1W7101/
(over)
DOH-1555 (02/2004)