Charland, Gloria Beatrice 52„,„------.
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Records y �,1' .LIi) Burial - Transit Permit
_/
Name First Middle Last Sex
Gloria Beatrice Charland Female
Date of Death Age If Veteran of U.S.Armed Forces,
12/10/2022 77 Years War or Dates
Place of Death Hospital,Institution or
ZCity,Town or Village Glens Falls Street Address Glens Falls Hospital
a Manner of Death ❑X Natural Cause Accident ❑Homicide OSuicide nUndetermined El Pending
W Circumstances Investigation
W Medical Certifier Name Title
0 Mathew Varughese DO
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 623
Burial Date Cemetery,Crematory or Facility Name
12/13/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
ZO❑Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
O. Date Point of
U)❑Transportation Shipment
Q by Common
Carrier Destination
Disinterment
Date Cemetery Address
EiReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
1. Remains are Shipped,If Other than Above
2 Address
IE
W
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/13/2022 Registrar of Vital Statistics Megan%11n(E(ectronica(TySigned)
(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: aa„„
ZL
W Date of Disposition It�IS I ZZ Place of Disposition 4-',AIL
2 (address)
W
CC (section) 4A4L.(lot number (grave number)
SName of Sexton or Person in Charge of Premises 4tease print)
W Signature / Title C1741742
DOH-1555(07/18)p id 2
I +`' (1
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#