Morey-Couse, Gail 4 4NEW YORK STATE DEPARTMENT OF HEALTH 3 Vital Records Section Burial - Transit P rmit
Name First Middle Last Sex
Gail Karen Morey-Couse Female
Date of Death Age If Veteran of U.S. Armed Forces,
June 3,2016 72 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
aManner of Death X Natural Cause Accident I 1 Homicide Suicide Undetermined Pending
.tit Circumstances Investigation
ui Medical Certifier Name Title
G: Cleaver Dr.
Address
HFHIN,Queensbury,NY 12804
Death Certificate Filed District Number SC��I Register Number ry /
City, Town or Village
❑Burial Date Cemetery or Crematory
Entombment June 6,2016 Pine View Crematory
Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date -I lace Removed
Z I I Removal and/or Held
5 2and/or Address
Hold
N
O Date Point of
N 1 j Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
I I Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
3809 Main Street, Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
F- Remains are Shipped, If Other than Above
Address
le
AU
!L. Permission is hereby granted to dispose of the humT-remains described abov- indicated.
Date Issued 0 Registrar of Vital Statistics ��
�l J O / (signature)
District Number 6,6 / Place � � _J C-e -41 -L
I certify that the remains of the decedent identified above were disposed of in acc rdance with this permit on:
W Date of Disposition (I (7 (/. Place of Disposition .c?.,&Li Cow.ctirr4--
W (address)
N
0 (section) /�f , (lo, t number (grave number)
pName of Sexton or Person in Charge of Premises ni J Q"
Z Tplease print)
W Signature 0 Title aH4faC
(over)
DOH-1555 (02/2004)