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Gorham, Carol E 113 NEW YORK STATE DEPARTMENT OF HEALTH #' .'9 �' -7 Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Carol E Gorham Female Date of Death Age If Veteran of U.S.Armed Forces, 09/12/2023 79 Years War or Dates F Place of Death Hospital,Institution or Z City,Town or Village Queensbury Town Street Address 6 Rudley Drive,Queensbury Town, New York 12804 UJ O Manner of Death EI Natural Cause illAccident Homicide El Suicide illUndetermined El Pending ILI 0 Circumstances Investigation U W Medical Certifier Name Title O Karen Going NP Address 325 Main Street,Hudson Falls Village,New York 12839 Death Certificate Filed Town Of Queensbury District Number Register Number City,Town or Village 5657 145 Burial Date Cemetery,Crematory or Facility Name 09/13/2023 Pine View Crematory Entombment _ Address ©Cremation Queensbury Town, New York Donation Z❑Removal Date Place Removed and/or and/or Held H Hold Address N 0 O. Date Point of U)nTransportation CI Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Brewer Funeral Home Inc 00211 Address 24 Church Street PO Box 500, Lake Luzerne,New York 12846 Name of Funeral Firm Making Disposition or to Whom H Remains are Shipped,If Other than Above 2 Address CC W IL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 09/13/2023 Registrar of Vital Statistics Caroline Hildegarde Barber(Electronically Signed) (signature) District Number 5657 Place Town Of Queensbury H I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition 1115 ?3 Place of Disposition ,, L14____ 2 (address) W N Lt (section) (lot number) (grave number) Name of Sexton or Person in Charge of Premises dr-v Z / (pise print) tL Signature Title it__ rf ii�e DOH-1555(07/18)p 1 of 2 - v 1 l,1 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , Pine View Cemetery . Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#