Herrick, Gloria NEW YORK STATE DEPARTMENT OF HEALTI 1
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Gloria E Herrick Female
Date of Death Age If Veteran of U.S. Armed Forces,
12/04/2018 93 Years War or Dates
N.
tn
Place of Death Hospital, Institution or
City, Town or Village Saratoga Springs Street Address Wesley Health Care Center Inc
Manner of Death f Natural Cause El Accident Homicide El Suicide �Undetermined Pending
LIAJ Circumstances Investigation
Medical Certifier Name Title
Diane Westbrook NP
ka
4,01 Address
vt 131 Lawrence St,Saratoga Springs,New York 12866
• Death Certificate Filed District Number Register Number
- City, Town or Village Saratoga Springs 4501 633
°.❑Burial Date Cemetery or Crematory
12/06/2018 Pineview Crematory
p:-: ['Entombment Address
®Cremation Queensbury, New York
Date Place Removed
❑Removal
and/or Held
and/or Address
1 Hold
; i Date Point of
[:Transportation Shipment
, by Common Destination
Carrier
Q Disinterment Date Cemetery Address
zm,Q Reinterment Date Cemetery Address
ler
Permit Issued to Registration Number
, Name of Funeral Home Densmore Funeral Home Inc 00448
Address
7 Sherman Ave,Corinth,New York 12822
Name of Funeral Firm Making Disposition or to Whom
, Remains are Shipped, If Other than Above
��oY
• Address
q
-! Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/06/2018 Registrar of Vital Statistics John P Franc&(ECectronicalfy Signed)
(signature)
, District Number 4501 Place Saratoga Springs, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
.' Date of Disposition IV-1/IA' Place of Disposition p;,,e V;cw, Ci'trti,q,i'or
w (address
(section) (lot number) (grave number)
t Name of Sexton or Person in Charge of Premises 1il°�t`ke 1 / r J Signature (It� p Title (please print)
Hlt 1 L C(Q(h .4..ar
(over)
DOH-1555 (02/2004)