Goodell, Helen s 4 .t Si
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Helen Goodell Female
Date of Death Age If Veteran of U.S. Armed Forces,
January 16, 2014 98 War or Dates
Place of Death Hospital, Institution or
iZ City, Town or Village Queensbury Street Address 35 Evergreen Lane
c5 Manner of Death in Natural Cause D Accident n Homicide n Suicide ❑Undetermined n Pending
Circumstances Investigation
w Medical Certifier Name Title
Ci Patricia Auer
Address
Carey Rd,Queensbury,NY 12804
Death Certificate Filed District Number Reeter Number
City, Town or Village Queensbury 5657
❑Burial Date Z Cemetery or Crematory
January,2014 Pine View Crematorium
❑Entombment Address
®Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z ❑Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
Permit issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped, If Other than Above
2 Address
IX
W
O.
Permission is hereby granted to dispose of the humane ains described ove as indicated.
Date Issued l ( 2N --) Registrar of Vital Statistics [ )C� �---,
(signature)
District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z '
W Date of Disposition I /231I4 Place of Disposition �r.e \)ff) L„ {ur,d,..
2 (address)
W
0 (section) / (lot umber) (grave number)
p Name of Sexton or Person,in Charge of Premises G 6r SPnrgt
Z (pl ase print)
W Signature Title QZ04ATA(
(over)
DOH-1555(02/2004)