Gifford, Margaret NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Margaret Shirley Gifford Female
c.:, Date of Death Age If Veteran of U.S. Armed Forces,
03/10/2018 90 Years War or Dates
Place of Death Hospital, Institution or —_
City, Town or Village Scotia Village Street Address Baptist Health Nursing And Rehabilitation Center,Inc
Manner of Death Natural Cause ❑Accident ❑Homicide 0 Suicide nUndetermined n Pending
4-1 Circumstances Investigation
Medical Certifier Name Title
al Ronald Otwori NP
Address
,p 297 N Ballston Ave,Scotia Village,New York 12302
:, Death Certificate Filed District Number Register Number
City, Town or Village Scotia Village 4620 031
❑Burial Date Cemetery or Crematory
03/12/2018 Pine View Crematorium
; ❑Entombment Address
Cremation Queensbury Town, New York
<q
Date Place Removed
ri u Removal and/or Held
and/or Address
Hold
— Date Point of
to u Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address
r, 68 Main Stpo Box 67,Hudson Falls,New York 12839
a Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission Is hereby granted to dispose of the human remains described above as indicated.
Date issued 03/12/2018 Registrar of Vital Statistics Atria,Ann Sant*:( kctroni attySigneti
(signature)
District Number 4620 Place Scotia Village, New York
o
' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 31 Inc is y Place of Disposition .PTV,_ 4'4—
LL (address)
CA
(section) number (grave number)
Name of Sexton or Person in Charge of Premises (L(lot
• 4-
f1
( lease print)
4_
Signature Title ills_
(over)
DOH-1555 (02/2004)