Hogan, Gwendolyn NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Gwendolyn Sue Hogan Female
Date of Death Age If Veteran of U.S. Armed Forces,
April 11, 2016 61 War or Dates
Zac of Death Hospital, Institution or
City Town or Village Glens Falls Street Address Glens Falls Hospital
W` nner of Death Natural Cause 0 Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
Aqeel A. Gillani, M.D. Dr.
Address
102 Park St Glens Falls, NY 12801
th Certificate Filed District Number Register Number
ice, own or Village5601
� )� 9 �e cm 1�c ckt7
❑Burial Date Cemetery or Crematory
April 13, 2016 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
zriRemoval and/or Held
▪ and/or Address
• Hold
vi Date Point of
a. ❑Transportation Shipment
CO by Common Destination
O. Carrier
Disinterment Date Cemetery Address
5 Date Cemetery Address0 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
I— Remains are Shipped, If Other than Above
• Address
t,t
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued I-1. 4 1 3 I j6 Registrar of Vital Statistics U\).A/\4
11 (signs Lure)
District Number 5601 Place 6 (szM 5 -02 l 1 5 , GU V
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H,
,, Date of Disposition 04/13/2016 Place of Disposition Quaker Road Queensbury,NY 12804
2;,' (address)
w
e (section) (lot nurpber) (grave number)
aName of Sexton or Person in Charge of Premi s ` , 3 044*
e� (please print)
W Signature ( Title tipg_
(over)
DOH-1555 (02/2004)