Goodwin, Darlene Cynthia # Itia
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Records Burial - Transit Permit
Name First Middle Last I Sex
Darlene Cynthia Goodwin Female
Date of Death Age If Veteran of U.S.Armed Forces,
03/01/2022 67 Years War or Dates
H Place of Death Hospital,Institution or
WCity,Town or Village Glens Falls Street Address Glens Falls Hospital
O Manner of Death El Natural Cause Accident Homicide 0Suicide Undetermined ❑Pending
iW
✓ Circumstances Investigation
Q Medical Certifier Name Title
Michael Miles MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 136
Burial Ed
Entombment Date Cemetery,Crematory or Facility Name
03/04/2022 Pine View Crematorium
Address
Cremation Queensbury Town,New York
Donation
❑Removal Date Place Removed
F and/or and/or Held
N Hold Address
0
O. Date Point of
Cl)❑Transportation
p by Common Shipment
Carrier Destination
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 Street,P.O.Box 67,Hudson Falls,New York 12839
Name of Funeral Firm Making Disposition or to Whom
j Remains are Shipped,If Other than Above
a Address
Q
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/03/2022 Registrar of Vital Statistics Megan Wolin(ECectronicafySigned)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
WDate of Disposition 314 I it Place of Disposition47.411%-- 40---.....
W (address)
V)
8 (secnbn/ (lot number/ ,, (grave number)
Name of Sexton or Person in Charge of P ises �i: l__int) d ft
z (pleise print)
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Signature / Title fiZUJ
' it's
DOH-1555(07/18)p 1 of 2
U `!,_ 58s 0
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#