Godlewski, Joan NEW YORK STATE DEPARTMENT OF HEALTH , �3Z
Vital Records Section V, Burial - Transit Permit
r' Name First Middle Last Sex
Joan M. Godlewski Female
�,,, Date of Death Age If Veteran of U.S. Armed Forces,
June 27, 2012 70 War or Dates
44 Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Deathwki Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
� David Cunningham,MD
Address
Glens Falls,NY
, Death Certificate Filed District Number Register Number
4 City, Town or Village Glens Falls,NY 5601 (`��
❑Burial Date Cemetery or Crematory
June 29, 2012 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ ❑Removal and/or Held
2 and/or Address
H Hold
O Date Point of
y ❑Transportation Shipment
p by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
P• ermit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
F; Address
a 53 Quaker Road, Queensbury,NY 12804
N• ame of Funeral Firm Making Disposition or to Whom
i'` Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains descri ed a ov las i . ted.
�/Z Date Issued 0�� 0/x-- Registrar of Vital Statistics
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(signature)
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition GM jet Place of Disposition ,,,,,,U Cry—ki2r{�.�
W (address)
CO
W (section) Ari
(lot number) (grave number)
pName of Sexton or Person in C arge of Premises ser• _.)Vari-
`Z (please print)
il1/4
Signature \ Title Cbtic rvrlr C
(over)
DOH-1555(02/2004)