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Dickinson, Rena NEW YORK STATE DEPARTMENT OF HEALT Vital Records Section Burial - Transit Permit Name First Middle Last Sex x Rena Lavona Dickinson Female ', Date of Death a If Ve ran of U.S. Armed Forces, ': 11/15/2017 87 ars Vyttir or Dates IPlace of Death Hospital, Institution or City, Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc Manner of Death©Natural Cause Accident Homicide Suicide �Undetermined ❑Pending Lti Circumstances Investigation I Medical Certifier Name Title Philip Gara MD Address 319 Broadway,Fort Edward Town,New York 12828 Death Certificate Filed District Number Register Number City, Town or Village Fort Edward 5755 51 f&. ❑Burial Date Cemetery or Crematory 11/17/2017 Pine View Crematory ❑E ntornbnnent - ..., Address ®Cremation Queensbury Town, New York Date Place Removed Removal and/or Held and/or Address Hold Date Point of ❑Transportation Shipment by Common Destination Carrier s El Disinterment Date Cemetery Address Q Reinterment Date Cemetery Address Permit Issued to Registration Number tl 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 it Remains are Shipped, If Other than Above Address Permission is hereby granted to dispose of the human remains described above as indicated. 4, . '', Date Issued 11/20/2017 Registrar of Vital Statistics Aimee liahoney EfectmnicaaySigned (signature) District Number 5755 Place Fort Edward, New York i, I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition li/27 (0 Place of Disposition -er tJ. (Liu — (address) I (section) ,/(lot number) (grave number) Name of Sexton or Person in Charge of Premises i^rLE11���- �i��'tt a (plebse print) 10 Signature _ Title fitkrstrf11_. (over) DOH-1555 (02/2004)