Gosselink, Katherine 4 %NEW YORK STATE DEPARTMENT OF HEALTH O1f11
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Katherine H. Gosselink Female
Date of Death Age If Veteran of U.S. Armed Forces,
0 3/0 1/2 01 4 87 yrG _ War or Dates No
14 Place of Death Town of Hospital, Institution or
• City, Town or Village Putnam Station Street Address 249 County Rte. 3
ilk; Manner of Death Natural Cause n Accident Homicide 0 Suicide Undetermined Pending
t Circumstances Investigation
O.
iii Medical Certifier Name Title
0 Glen Chapman M.D.
Address
P.O. Box 29, ,Ticonderoga, NY 12883
Death Certificate Filed Town of District Number Register Number
City, Town or Village Putnam Station 5763 1
0 Burial Date Cemetery or Crematory
Entombment 0 3/0 5/2 01 4 Pine View Crematory
Address
Cremation Queensbury, New York
Date Place Removed
Z ❑Removal and/or Held
2 and/or Address
I.
Hold
IA
O Date Point of
❑Transportation Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01 821
Address
11 Algonkin St. , Ticonderoga, NY 12883
Name of Funeral Firm Making Disposition or to Whom
lii4. Remains are Shipped, If Other than Above
2 Address
cr
fa
P' Permission is hereby granted to dispose of the human rem ' s described above as indicated.
Date Issued 3 S— i `T Registrar of Vital Statistics ai -, ��Q �
(signature)
District Number 617603 Place row n O -/2 At //1 a./r) J/U 17 c) n
I
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
z.
LLI Date of Disposition 3h10 Jlq Place of Disposition -(� .d C* rr.--
2 (address)
LU
Ul
CC (section) ��j (lot number) (grave number)
ca Name of Sexton or Person in Charge o Premises l h.,, JihN
Z (pl ase print)
Iii
Signature 4L1_ Title G1 . �
(over)
DOH-1555 (02/2004)