Dines, Letha NEWYORKSTATEDEPARTMENTOFHEALTH Burial - Transit Permit
Bureau of Biostatistics - Vital Records Section
Miii Name First Middle Last €: Sex
L: t.ha:::::::::::::::::::::.:::::.::.:::::::::::::::::P: Di nes... ... ::...Femal e
IF Date of Death Age If Veteran of U.S.Armed Forces,
9/6/87 78 War or Dates No
Place of Death Hospital, Institution or
City,Town or Village Town of Queensbury Street Address 35 Cottage Hi 11 Road
:'t ..........................
.............................................................................................................................................................................................................
. Cause of Death
AU cardio-pulmonary arrest
:t 1 Medical Certifier Name Title
CI Michael J. Crook MD
Address
62 Elm Street, Glens Falls , N. Y. 12801
;:..:Death Certificate Filed:::::.:.............................................................. .. ... ............................................... ......................
7.......__..........................::::::: .:::::.:. ::::::::.::..._..................
District Number Register Number
City,Town or Village Town of Queensbury 51] ry
i Date Cemetery or Crematory
®Burial 9/9/87 Pine View Cemetery
❑Cremation Address
Queensbury, New York 12801
z Date Place Removed
O, ❑ Removal and/or Held
f:., and/or Hold>.......::.......:...:.....:..:.:.....................:...::.......................:..:...:..... .........................:....
Address
O........::....... ...................................
Z. > Date Point of
to ['Transportation by Shipment
Common Carrier
Destination
❑ Disinterment
Date Cemetery Address
El Reinterment
Date Cemetery Address.:...:........:.......:..................:....::. .
Permit Issued to Registration Number
Name of Funeral Firm Regan & Denny, Inc. , ! 02883
; . Address:::.::...............................................................................................................................................................................................................................................
iiiiiiiii 40 Quaker Road, Glens Falls, N. Y. 12801
:.:::.Name of FuneralFirm Making Disposition or to Whom
Remains are Shipped, If Other than Above
itit Address
AU
is
ga Permission Is hereby granted to dispose of the dead hu remains described e as indicated.
Date Issued 7 -9 d 7 Registrar of Vital Statistics �:,_._124.e.....^
(sign re)
Mi District Number S 7 Place cre.....,-,-,-,
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F
W q Date of Disposition / — 2 7 Place of Disposition p,'j f V i�w C�rirteT-t-y u -,. k,kJ
(address)
W /�udS'0ott *' /14—P''l J
(section) (lot number) (grave number)
aName of Secton or Person in Charge of Premises R a et N 4R.y G . Wk_c,S t_j.-
Z. (please print) /
- Signature -.., t f)y`( Title .72 t,r ( ,
DOH-1555 (9/86)p 1 of 2(formerly VS-61)