Gaulin, Charlotte NEW YORK STATE DEPARTMENT OF HEAL_ , RS
Vital Records Section Burial - Transit t'ermit
Name First Middle - Last Sex
Charlotte L. Gaulin Female
Date of Death Age If Veteran of U.S. Armed Forces,
July 12, 2014 89 War or Dates
Place of Death Hospital, Institution or
Ci
laty, Town or Village Street Address
W Manner of Death Natural Cause 0 Accident 0 Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
0 Sharon H Shannon,
Address
9 Cary Rd Queensbury, NY 12804
, Death Certificate Filed District Num Register b r
City, Town or Village �,601
0 Burial Date Cemetery or Crematory
July 14, 2014 Pine View Crematorium
4 0 Entombment Address
'm
®Cremation Quaker Road Queensbi ry,NY 12804
Date Place Removed
zriRemoval and/or Held
C and/or Address
:. Hold Pine View Crematorium
to
Date Point of
, : I I Transportation Shipment
CO by Common Destination
1+' Carrier
riDisinterment Date Cemetery Address
Reinterment Date Cemetery Address
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
}.-f Remains are Shipped, If Other than Above
• Address
CC
'al
Ci.'"' Permission is hereby gr nted to dispose of the human remains desc ib 7/7s ' ' ed.
Date Issued 67 /t !i Registrar of Vital Statistics
// (signature)
District Number t�'4 0/ Place ?/ , /U,Y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition 07/14/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
U Saratoga
Nat ft; y A (1ot number (grave number)
Ceme.ery
f• Name of Sexton or Person in harge of remises L""1c Ndtt
( ease print)
2' R
W Signature -.5.-- Title Ca aw" f ,nM�n
_
(over)
DOH-1555 (02/2004)