Bogardus, Clara NEW YORK STATE DEPARTMENT OF HEALTH IT h J
Vital Records Section Burial - Transit Permit
'1 Name First Middle Last Sex
Clara Esther Bogardus Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 22, 2014 90 War or Dates
wPlace of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death J Natural Cause Li Accident 0 Homicide n Suicide Undetermined ri Pending
Circumstances Investigation
W Medical Certifier Name Title
13` Michael Miles, M.D
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
ii' City, Town or Village 5601 1 1.4 i
0,, 0 Burial Date Cemetery or Crematory
March 24, 2014 Pine View Crematorium
❑Entombment Address
'®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z riRemoval and/or Held
0, and/or Address
F. Hold
CO Date Point of
LEI Transportation Shipment
by Common Destination
Q Carrier
Disinterment Date Cemetery Address
U
' 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-4:'', Remains are Shipped, If Other than Above
2i. Address
I '
t.
Permission is hereby granted to dispose of the human remains described above ag indicated.
Date Issued Registrar of Vital Statistics OA '�~� "''
(signature
6
District Number 5601 Place S IV,`S ki y
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
AuZ
Date of Disposition--- - -__ Place of Disposition - --- • .- - - ar ulf:-.0 Cn {ati4--'
3I cbq (address)
iii,Cli
(section) (lot nber) (grave number)
Name of Sexton or Perso in Charge of Premises lhi. , kOl
z (please pri t)
W Signature L - .�' Title G 01
(over)
DOH-1555 (02/2004)