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Levine, Gloria NEW YORK STATE DEPARTMENT OF HEALTH r . iie433 Vital Records Section Burial - Transit Permit :; Name First Middle Last Sex Gloria Levine Female ruc Nit Date of Death Age If Veteran of U.S. Armed Forces, January 7, 2016 87 War or Dates _ Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death mJ Natural Cause El Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending �_ilt Circumstances Investigation 1A( Medical Certifierame ,rki0 Title Add ess (i'c �J � Death Certificate Filed District Number Regis Regis11 tuber City, Town or Village 5601 ' ❑Burial Date Cemetery or Crematory January 11, 2016 Pine View Crematorium ❑Entombment Address Nia©Cremation Quaker Road Queensbury,NY 12804 ' Date Place Removed z ❑ Removal and/or Held 0, and/or Address Hold Date Point of Ai❑Transportation Shipment by Common Destination Carrier Disinterment Date Cemetery Address ❑ 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 ;M Address Ea' I' Permission is hereby granted to dispose of the human remains described above al Indic ted. Date Issued i i t t ) 1 t Registrar of Vital Statistics W(AA,j), (signatu ) District Number 5601 Place 6 (s2„,.s T Ci, \ 5 l N� I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: `` Date of Disposition 01/11/2016 Place of Disposition Quaker Road Queensbury,NY 12804 " ` (address) L:. (t (section) jot number) (grave number) Name of Sexton or Person in Charge of Premises 74 f,• ^ �i v) Z (please print) W,_ i Signature <-1- 4L`-tiHrf Title .t4fr 2 (over) DOH-1555 (02/2004)