Gebauer, Florence NEW YORK STATE DEPARTMENT OF HEALt HA - It
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Florence L. Gebauer Female
Date of Death Age If Veteran of U.S. Armed Forces,
01/04/2013 79 years War or Dates
i.: Place of Death Hospital, Institution or
Ei City, T r Street Address
JP��R Saratoga S rings Wesley Health Care Center
0 Manner of Death Natural Cause 11111 Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
CU Circumstances Investigation
til Medical Certifier Name Title
L Rick D Teetz M. D.
Address
131 Lawrence Street, Saratoga Springs N Y
Death Certificate Filed District Number Register Number
City, Tnviopr l R Saratoga Springs 4501 11
❑Burial Date Cemetery or Crematory
❑Entombment 01/07/2013 I Pineview Crematorium
Address
iii[;]Cremation Queensbury N Y
Date Place Removed
Z Removal and/or Held
9[—I and/or Address
F Hold
N
0 Date Point of
❑Transportation Shipment
G by Common Destination
iig Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
NiiPermit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home 00448
iM Address
7 Sherman Ave, Corinth, New York 12822
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
a Address
ir
LU
9! Permission is hereby granted to dispose of the human remai cri d above indicate .
Date Issued 01/07/2013 Registrar of Vital Statistics r
(signature)
District Number 4501 Place Saratoga Springs
_';. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
til Date of Disposition i-"-13 Place of Disposition „,si Ukv Cel„,./{or,,,,�
(address)
Ili
to
t (section) 4 (lot number (grave number)
Name of Sexton or Person in Charge f Premises t L se tirr�
2 (pha print)
`
iWro Signature ` 1, Title C4. ►ArdP_,
(over)
DOH-1555 (02/2004)