Gosch, Julie S NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Julie S. Gosch female
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Date of Death Age If Veteran of U.S.Armed Forces,
April 29, 1991 54 War or Dates No
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Z Place of Death Hospital, Institution or
W City Town or Village City of Glens Falls Street Address Glens Falls Hospital
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W fdtanner of Death Natural Cause Accident Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
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Medical Cert'rfier Name Title
Qj S. Richard Spitzer MD
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Address
90 South Street, Glens Falls N. Y. 12801
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Death Certificate Filed District Number Register Number
City,Town or Village City of Glens Falls
Date Cemetery or Crematory
❑Burial May::.2.,.. 1991. Pine:View...Crernat..ry.......: ............
®Cremation Address
. ........................Town :ofQu.eonsbur.y.,. N.::::Y.. ..
z Date Place Removed
0 Removal and/or Held
and/or Hold ... . .:::: ........- .......
Address
N
o:... . .:..: .......
(3L< Date Point of
N' ]Transportation by Shipment
pl Common Carrier
Destination
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El Disinterment
Date Cemetery Address
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Reinterment
Date Cemetery Address
El
Permit Issued to Registration Number
Name of Funeral Firm Regan and Denny Funeral.:Svc .,._.1nc.....,,:: „01634
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Address
26 Quaker Road,, Q:ueensbury:. N..::::Y.. ::12804:::::::. __., ::::.. . .
-; Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
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Address
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ut<
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Permission
�is/ hereby granted to dispose of the human remains described above as indicated.
Date Issued Registrar of Vital Statistics
(signature)
District Nu Place c
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Dispositio Place of Disposition
2 (address)
W
N (section) (lot number) (grave number)
cr
pName of Sexton or erson in C rge of Premi s ,l/'lc/ //`� C
Z (please print) t
W' Signature Title
DOH-1555 (10/89) p. 1 of 2 VS-61