Bontecou, Dorothy NEW YORK STATE DEPARTMENT OF HEALTH /
Vital Records Section ' Burial - Transit Permit
i Name First Middle Last Sex
DOROTHY E. EONTECOU Female
Date of Death Age If Veteran of U.S. Armed Forces,
Mi Agri l 07, 2006 84 War or Dates
Place of Death Hospital, Institution or
• City, Town or Village Harrietstown Street AddressAdri� Medical Center
tillManner of Death 0 Natural Cause Accident 0 Homicide 0 Suicide Undetermined Pending
A Circumstances Investigation
Medical Certifieriti Name Title
Wit 1 tam V1scARDO, TW
Address
iN
Adr'c MP(3i rat CPniPr, Saranac Take, NY
Death Certificate Filed District Number Register Number
City, Town or Village HarriP1-ctn„n 1663
Date Cemetery or Crematory
❑Burial April 12, 2006 Pine View Crematory
Address
CICremation Glens Falls, NY
Date Place Removed
0 ❑Removal and/or Held
— and/or Address
— Hold
O Date Point of
0 Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to AM. (Clark.lat. Registration Number
Name of Funeral Home 2310 Saranac Ave. 0 11 4 6
Address Lake Placid, NY 12946
;ii> Name of Funeral Firm Making Disposition or to Whom
tt Remains are Shipped, If Other than Above
iX
Address
6.1
iiM Permission is hereby granted to dispose of the hum. - ains described a ove as indicated.
IiIN
la iligDate Issued_04/09/06 Registrar of Vital Statisti - `o ����{) t�
(sig lure)
'. District Number 1663 Place 3 ✓`_a je , f k 9 63
I certify that the remains of the decedent identified above were disposed of in acco ance with this permit on:
1- �1
Date of Disposition �{��� �V Place of Disposition Pt/It i¢vk} t`0"4.401',4,.
;; (address)
w
N
C4 (section) /, Jot number) (grave number)
GName of Sexton or Person in Charge of Premises L. �+^ 1 �e,,ate`
�/�w /^ (please print) ,
Signature ! 4V4 h�ovmt - Title Lfrm ►(
(over)
DOH-1555 (9/98)