Gardner, Penelope NEW YORK STATE DEPARTMENT OF HEALTH CC!! 1
Vital Records Section N Burial - Transit Permit
r Name First Middle Last Sex
Penelope Marie Gardner Female
Date of Death Age If Veteran of U.S. Armed Forces,
08/15/2018 71 Years War or Dates
• Place of Death Hospital, Institution or
• City, Town or Village Granville Town Street Address The Orchard Nursing And Rehabilitation Centre
O Manner of Death®Natural Cause El Accident El Homicide El Suicide El Undetermined El Pending
W Circumstances Investigation
W Medical Certifier Name Title
a Leonard Gelman MD
Address
-, 10421 State Route 40,Granville Town.New York 12832
Death Certificate Filed District Number Register Number
s' City, Town or Village Granville 5756 36
❑Burial Date Cemetery or Crematory
08/15/2018 Pine View Crematorium
❑Entombment Address
Cremation Queensbury Town, New York
Date Place Removed
Removal and/or Held
and/or Address
— Hold
0
O Date Point of
0LjTransportation Shipment
a by Common Destination
Carrier
El
Disinterment Date Cemetery Address
�� Reinterment Date Cemetery Address
`- Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address
68 Main Stpo Box 67,Hudson Fails,New York 12839
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
MOO-
2 Address
te
e Permission is hereby granted to dispose of the human remains described above as indicated.
, Date Issued 08/15/2018 Registrar of Vital Statistics jenny Linda Illartea 1Efctronic lyySigne i
1 ,.
(signature)
District Number 5756 Place Granville, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
W Date of Disposition 111(.11g Place of Disposition P14., e ,-..
W (address)
tli
(section) (lot number)/► c (grave number)
Name of Sexton or Person in Charge of Premises ( Ar,,1o�64.. J�•�
z (please print)
Signature Title (Iq
(over)
DOH-1555 (02/2004)