Gordon, Dorothy NEW YORK STATE DEPARTMENT OF HEALTH ( C°G
Vital Records Section Burial - Transit Permit
1 Name First Middle Last Sex
Dorothy Lillian Gordon Female
Date of Death Age If Veteran of U.S. Armed Forces,
October 19, 2014 72 War or Dates
I• Place of Death Hospital, Institution or
WCity, Town or Village Glens Falls Street Address Glens Falls Hospital
WManner of Death iirzriNatural Cause ❑ Accident ❑Homicide ❑ Suicide ❑ Undetermined ❑ Pending
0 Circumstances Investigation
W Medical Certifier Name Title
CI Scott Biasetti, M.D. Dr.
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number % Registerpur bes
City, Town or Village XX��
❑Burial Date Cemetery or Crematory
October 21, 2014 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z El Removal and/or Held
_
p l_J and/or Address
Hold Pine View Crematorium
0 Date Point of
a. ❑Transportation Shipment
by Common Destination
Cl Carrier
Date i Cemetery Address
❑ Disinterment
Date Cemetery Address
El 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
2 Address
W
a Permission is hereby granted to dispose of the human remains describe o e nd".
Date Issued io/ /24/V Registrar of Vita! Statistics P✓.
(signature)
District Number ,5( //0/ Place t�/4 /1/; 4'y /28a/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 10/21/2014 Place of Disposition Quaker Road Queensbury,NY 12804
Z (address)
W'
co
r' (section) ,f (lot number) (grave number)
0. itie Name of Sexton or Person in Charge of Premises nr S„�,�
Z (pl r ase print)
W Signature AttL Title CaeMr
(over)
DOH-1555 (02/2004)