Mallaney, Gwendolyn Ann NEW YORK STATE DEPARTMENT OF HEALTH �L,_ , a-i-
Bureau of Vital Records `�—�` Burial Transit Pe
Name First Middle Last Sex
Gwendolyn Ann Mallaney {` Female
Date of Death Age If Veteran of U.S.Armed Forces,
09/18/2022 64 Years War or Dates
F— Place of Death Hospital,Institution or
Z City,Town or Village Hudson Falls Village Street Address 3 Forrest Street, Hudson Falls Village, New York 12839
WW Pending
Manner of Death ❑X Natural Cause ❑Accident Homicide Suicide I nUndetermined
0 Circumstances Investigation
W Medical Certifier Name Title
O Howard Silverberg MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed Village Of Hudson Falls District Number Register Number
City,Town or Village 5726 42
Burial Date Cemetery,Crematory or Facility Name
09/20/2022 Pine View Crematorium
Entombment Address
Cremation Queensbury Town,New York
Donation
6❑Removal Date Place Removed
and/or and/or Held
17:0 Hold Address
0
a. Date Point of
CO EiTransportation
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
F— Remains are Shipped,If Other than Above
N Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/20/2022 Registrar of Vital Statistics Cynthia (Bardin(E(ectronica1tySigned)
(signature/
District Number 5726 Place Village Of Hudson Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
. -� 4"---
&
Z Date of Disposition q I�3I 1Z Place of Disposition
W (address)
ILLI
CCCC (section) (lot number) (grave number)
4 -'i"8 Name of Sexton or Person in Charge Premises f' i rf+
leass e print/j
W Signature Title ` R'(A��K_
DOH-1555(07/18)p 1 of 2
..."(
Public Health Law Sec. 4145(2b)
Receipt " ' foit
Human remains of " delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#