Gollhofer, Ruth NEW YORK STATE DEPARTMENT OF HEALTH # Z37 Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Ruth Lynn Gollhofer Female
Date of Death Age If Veteran of U.S. Armed Forces,
03 / 21 / 2015 70 War or Dates N/A
'}.i.. Place of Death Hospital, Institution or
' City, Town or Village Albany Street Address Albany Medical Center
iD Manner of Death® Natural Cause 0 Accident E Homicide E Suicide � Undetermined Pending
lu Circumstances Investigation
tu Medical Certifier Name Title
Jessica Johnson M.D.
Address
43 New Scotland Ave., Albany, NY 12208
Death Certificate Filed District Number 1 Q i Register Number
City, Town or Village Albany (¢4C(
>>>EJBurial Date Cemetery or Crematory
03 / 31 / 2015
' Pine View Crematory
Entombment Address
Cremation Queensbury, New York
__.__.._ — Date Place Removed
Z Removal and/or Held
2�and/or Address
i= Hold
Cl)
19 Date Point of
Transportation Shipment
f by Common Destination
Carrier
Q Disinterment Date Cemetery Address
itiQ Reinterment Date Cemetery Address
]iiiinPermit 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
Remains are Shipped, If Other than Above
2 Address
#X
III
) Permission is hereb granted to dispose of the human re ains described ove/as indicated.
IN Date Issued 31aq (S Registrar of Vital Statistics ��
(signature)
District Number t'p ( Place e 'P Albany , New York
iiiM
l —
FI certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tiii Date of Disposition 3j 3j lig Place of Disposition f j,,r (t -'4 r,,.,.,
2 (address)
Cl,
Q (section) (lot numb r) (grave number)
IIName of Sexton or Person in Char of Premises ,At number)
Z (please print) •
it Signature I4. Title (afpoipc
(over)
DOH-1555 (02/2004)